Update 2006 Therapy Cap Exception Process
The Centers for Medicare and Medicaid Services (CMS) issued implementation instructions to its contractors on February 13, 2006, outlining the congressionally mandated exception process for the Medicare outpatient therapy caps that went into effect in January 1, 2006. Please access the CMS instructions and two overview documents prepared by ASHA regarding the exception process and the documentation requirements by clicking on the link: http://www.asha.org/members/issues/reimbursement/exception_process.
Although Medicare contractors will have 30 days in which to implement the exceptions process, speech-language pathologists (SLPs) may begin submitting requests for services that both exceed the cap and meet the criteria outlined in the CMS instructions. SLPs are also urged to review their local contractor’s web sites for additional information.
SLP Services Included in the Exception Process
In brief, CMS will allow an automatic exception for services to beneficiaries whose diagnosis requires both speech-language pathology services and physical therapy concurrently, when all of the services are medically necessary and the need for extended services is documented. SLPs are required to use a KX modifier with each line of service that meets the requirements for exception. The KX modifier should only be used in those cases where the clinical record clearly indicates that the individual patient is in need of additional covered services during the episode of care. Frequent use of the KX modifier could elicit additional scrutiny by the contractor.
CMS outlines two other methods to implement the Medicare therapy cap exception process beyond the joint SLP/PT concurrent care exception:
1) an automatic exception for specific ICD-9 diagnosis codes; and
2) the provider can manually request their CMS contractor for additional services in excess of the cap.
A written request to the contractor is not required for automatic exceptions, but is required for manual exception requests. A listing of excepted diagnoses is contained in ASHA’s overview document on the exception process.
Documentation continues to be critical in evaluating the need for therapy services. CMS provided detailed guidance on documentation requirements. Documentation needs to support treatment and include objective evidence or clinical indicators which show that:
- the patient has the potential to improve;
- maximum improvement by the patient is yet to be attained;
- and patient improvement is attainable within a generally predictable period of time.
CMS indicates in their documentation guidance that outcomes measurement tools can be beneficial in justifying exceptions for outpatient therapy services. ASHA’s National Outcomes Measurement System (NOMS) is a functional assessment tool that can assist SLPs in justifying the need for therapy services. More information on NOMS can be found at: http://www.asha.org/members/research/NOMS/.
ASHA will host a telephone seminar about the exceptions process on Thursday, March 9th from 1 – 3 p.m., EST. To register for this telephone seminar, please visit http://www.asha.org/about/continuing-ed/ASHA-courses/T/T0609.htm. For more information, please contact Ingrida Lusis, ASHA’s Director of Health Care Regulatory Advocacy, via email at firstname.lastname@example.org or by phone at 800-498-2071, ext. 4482.