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MIR-20007-1AB, January 2007
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Outpatient Therapy Cap Exceptions Clarifications
| Note: This article was revised on December 4, 2006, to reflect the correct effective and implementation dates as described in CR5271, which CMS recently revised. While CR5271 also reflects effective and implementation dates in January 2007 for Medicare system changes, the information in this article clarifies existing processes. |
Provider Types Affected
Providers, physicians, and non-physician practitioners (NPPs) who bill Medicare contractors (fiscal intermediaries (FIs) including regional home health intermediaries (RHHIs), Part A/B Medicare Administrative Contractors (A/B MACs), and carriers) under the Part B benefit for therapy services
Provider Action Needed
CR 4364, released February 15, 2006, described the exception process to the caps set on outpatient therapy services (physical therapy and occupational therapy). CR 5271, upon which this article is based, clarifies questions (below) that have arisen about this exception process. Thus, the article is meant primarily for informational purposes. It also reminds you that the exception process stops after December 31, 2006.
Background
A brief history may be beneficial at this point. The Balanced Budget Act of 1997 placed financial limitations on Medicare-covered therapy services (therapy caps), that were implemented in 1999 and again for a short time in 2003. Congress placed moratoria on these caps for 2004 and 2005, but the moratoria are no longer in place, and the caps were reimplemented on January 1, 2006. However, Congress, through the Deficit Reduction Act has provided that (only for calendar year 2006) exceptions to caps may be made when provision of additional therapy services is determined to be medically necessary. This process ends after December 31, 2006.
Review of this Exception Process
Section 1833(g)(5) of the Social Security Act provides that, for services provided during calendar year 2006, FIs, RHHIs, and carriers can, in certain circumstances, grant an exception to the therapy cap when requested by the individual enrolled under the Part B benefit (or by a person acting on behalf of that individual).
Exception Processes fall into two categories:
1) Automatic Process Exceptions
Medicare beneficiaries will be automatically excepted from the therapy cap and will not be required to submit requests for exception or supporting documentation if they meet specific conditions and complexities listed in the Medicare Claims Processing Manual, Publication 100-04, Chapter 5 (as revised by CR5271) for exception from the therapy cap for 2006.
2) Manual Process Exceptions
Medicare beneficiaries may be request an exception using the manual process for exception from the therapy cap if their providers believe that the beneficiaries will require more therapy visits than those payable under the therapy cap, but the patients do not meet at least one of the criteria for automatic exceptions.
The Clarifications to Questions Generated from CR 4364
Your FI, RHHI, or carrier:
- Will grant exceptions for any number of medically necessary services for 2006 that meet the automatic process exception criteria, if the beneficiary meets the conditions described in Medicare Claims Processing Manual, Pub. 100-04, Chapter 5 (as revised by CR5271).
- Will grant an exception to the therapy cap, by approving any number of additional therapy treatment days, when these additional treatment days are deemed medically necessary based on documentation that you have submitted for services provided in 2006.
- Will utilize clinical judgment in approving or disapproving requests for additional treatment days in the exceptional circumstance in which you do not submit all required documentation with the exception request for services provided in 2006.
- Must reply as soon as practicable to a request for exception for services provided in 2006. They will grant an exception to the therapy cap, approving the number of treatment days that you or the beneficiary request (not to exceed 15 future treatment days), if they do not make a decision within ten business days of receipt of any request and appropriate documentation.
- Will allow automatic process exceptions when medically necessary services are provided for two or more separate, billable, conditions in the same calendar year in 2006.
- Will follow the manual description for allowing exceptions when the same patient has two conditions or complexities in the same year, one of which qualifies the beneficiary for use of the automatic exception process for services provided in 2006.
- Will allow automatic process exceptions when complexities occur in combination with other conditions that may or may not be on the list in the Medicare Claims Processing Manual in 2006.
- Will, when a patient is being treated under the care of two physicians for separate conditions, accept as appropriate documentation either 1) A combined plan of care certified by one of the physicians/NPPs, or 2) Two separate plans of care certified by separate physicians/NPPs.
- Will update the list of exceptions in 2006 according to the changes provided in this transmittal. You should be aware that they may expand (but not contract) this list if their manual process exception decisions lead them to believe further exceptions should be allowed.
- Will not require the additional documentation that is encouraged but not required in the manuals.
- Will interpret a referral or an order or a plan of care dated after an evaluation, as certification of the plan to evaluate the patient when only an evaluation was performed. It is not required that a plan, order or referral be written prior to evaluation.
- Will not deny payment for reevaluation only because an evaluation or reevaluation was recently done, as long as documentation supports the need for reevaluation. A reevaluation may be appropriate prior to planned discharge for the purposes of determining whether goals have been met, or to provide further information, beyond that required to be included in the discharge summary, for the use of the physician or the treatment site at which treatment will be continued.
- Will require clinicians to write progress reports at least during each progress report period. Note that required elements of the Progress 1 Report that are written into the Treatment Notes or in a Plan of Care may acceptably fulfill the requirement for a progress report. In these instances, a separate progress report is not required.
- Will require, on pre- or postpay medical review of documentation, that when the services incident to a physician are provided by qualified personnel who are not therapists, the ordering or supervising physician/NPP must personally provide at least one treatment session during each progress report period and sign the progress report.
- Will continue to use Medicare Summary Notice (MSN) message 38.18 on all Medicare MSN forms, both in English and in Spanish. This message reads: “ALERT: Coverage by Medicare will be limited for outpatient physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT) services for services received on January 1, 2006 through December 31, 2006. The limits are $1,740 for PT and SLP combined and $1,740 for OT. Medicare pays up to 80 percent of the limits after the deductible has been met. These limits don’t apply to certain therapy approved by Medicare or to therapy you get at hospital outpatient departments, unless you are a resident of and occupy a Medicare-certified bed in a skilled nursing facility. If you have questions, please call 1-800-MEDICARE.”
- Will continue to enforce Local Coverage Determinations (LCDs).
Final Note: You should keep in mind that claims for services above the cap for which an exception is not granted will be denied as a benefit category denial, and the beneficiary will be liable.
Additional Information
You can find more information about outpatient therapy cap exceptions by going to CR5271, issued in three transmittals. As attachments to those transmittals, you will find updated manual sections for:
These manual revisions include numerous additional changes and clarifications.
If you have any questions, please contact your FI, RHHI, A/B MAC, or carrier at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip  .
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents
MLN Matters Number: MM5271 Revised
Pub. 100-4, Transmittal# R1106CP, CR# 5271
Pub. 100-2, Transmittal# R60BP, CR# 5271
Pub. 100-8, Transmittal# R171PI, CR# 5271
Related CR Release Date: November 9, 2006
Effective Date: December 9, 2006
Implementation Date: December 9, 2006
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