Medicare Information Resource, Issue 2006-6A: Automated Therapy Cap Exceptions

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MIR-2006-6A, June 2006

Automated Therapy Cap Exceptions

Empire Medicare Services would like to remind our provider community that the Therapy Cap Exception process is now in place for providers submitting 22X, 23X, 74X, and 75X bill types. Please review the Centers for Medicare and Medicaid Services (CMS) Web site to see the entire list of ICD-9-CM codes that qualify for the automated exception process. If the beneficiary diagnosis is one of those on the automated exception list, an exception application is not necessary, and the claims should be submitted with a KX modifier.

Where do I find the list of automated ICD-9-CM codes?

Go to the CMS Web site at http://www.cms.hhs.gov.
Click on Regulations and Guidance.
Under the Guidance section, click on manuals.
In the small box on the left of the screen, click on Internet-Only Manuals (IOMs).
Publication # 100-04Medicare Claims Processing Manual.
Chapter #5 : Part B Outpatient Rehabilitation and CORF Services.
Section 10.2 : The Financial Limitations.
Under the subset “C,” #3 ICD-9-CM Codes That Qualify for the Automatic Therapy Cap Exception Process Based Upon Clinical Condition or Complexity.

How do I use the automatic process?

Determine whether the therapy services are payable under Medicare guidelines, meaning the services are reasonable and necessary.
Compare your beneficiary’s diagnoses to the list of diagnosis codes (beneficiary conditions or co-morbidities) included in IOM Pub 100-4, Chapter 5, Section C. 3.
If you find your beneficiary’s diagnoses on the automated exception list and the service is payable under Medicare guidelines, append the KX modifier to submitted services.
- It is not necessary to request an exception for additional services for these beneficiaries; reimbursement will be made even if the cap limit has been exceeded.