My thoughts, feelings, and opinions, as yes, though in continuous agonizing pain, underweight for six foot, I can think. And feel. And wonder why they treat this the way they do. I don't run and if I walk, not on a wheel.
I welcome readers: those here to download and cheat, my apologies:
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Sunday, September 30, 2012
2006 RULING LIFTS MEDICARE CAP ON THERAPIES FOR RSD/CRPS: LINK TO CMS (RE-POST RSD HOPE)
Details for: OUTPATIENT THERAPY CAPS: EXCEPTIONS PROCESS REQUIRED BY THE DRA
For Immediate Release:
Wednesday, February 15, 2006
Contact:
CMS Office of Public Affairs 202-690-6145
OUTPATIENT THERAPY CAPS: EXCEPTIONS PROCESS REQUIRED BY THE DRA
Background: Section 4541
of the Balanced Budget Act of 1997 (BBA) required the Centers for
Medicare & Medicaid Services (CMS) to impose financial limitations
or caps on outpatient physical, speech-language and occupational therapy
services by all providers, other than hospital outpatient departments.
The law required a combined cap for physical therapy and
speech-language pathology, and a separate cap for occupational therapy.
Due to a series of moratoria enacted subsequently to the BBA, the caps
were only in effect in 1999 and for a few months in 2003. With the
expiration of the most recent moratorium, the caps were reinstated on
January 1, 2006 at $1,740 for each cap.
The President signed the Deficit Reduction Act of 2005 (DRA) into law
on February 8, 2006. The DRA directs CMS to create a process to allow
exceptions to therapy caps for certain medically necessary services
provided on or after January 1, 2006. The law mandates that if CMS does
not make a decision within 10 days, the services will be deemed to be
medically necessary. This fact sheet describes the exceptions process
which will be implemented by our claims processing contractors. Until
contractors are able to implement the exceptions process, they are
required to accept requests for adjustment of claims for services in
2006 that were denied for exceeding the caps.
Exceptions Process: CMS has established an exceptions
process that is effective retroactively to January 1, 2006. Providers,
whose claims have already been denied because of the caps, should
contact their carrier to request that the claim be reopened and reviewed
to determine if the beneficiary would have qualified for the
exception. In addition, providers who have not yet submitted claims for
services on or after January 1, 2006 that qualify for the exception,
should submit these claims for payment, and refund to the beneficiary
any private payments collected because of the cap.
The exceptions process allows for two types of exceptions to caps for medically necessary services:
Automatic Exceptions. Automatic exceptions for certain
conditions or complexities are allowed without a written request. A
request to the contractor for an exception is not required when services
related to these conditions and complexities, which are described
below, are appropriately provided and documented. We anticipate that
the majority of beneficiaries who require services in excess of the caps
will qualify for automatic exceptions.
Manual Exceptions. Manual exceptions require submission of a
written request by the beneficiary or provider and medical review by
the contractor responsible for processing the claims. If the patient
does not have a condition or complexity that allows automatic exception,
but is believed to require medically necessary services exceeding the
caps--the provider/supplier or beneficiary may fax a letter requesting
up to 15 treatment days of service beyond the cap. A treatment day is a
day on which one or more services are provided. The request must
include certain documentation, including a justification for the
request. Contractors will make a decision on the number of treatment
days they determine are medically necessary within 10 business days.
These requests for cap exceptions should be submitted prior to the date
the cap is expected to be surpassed to avoid placing the beneficiary at
risk of incurring the costs of treatment if the request is denied.
Automatic Exceptions to the Therapy Caps: Certain
diagnoses qualify for an automatic exception to the therapy caps, if the
condition or complexity has a direct and significant impact on the need
for course of therapy being provided and the additional treatment is
medically necessary. A list of these diagnoses is attached. For a
condition or complexity to qualify the beneficiary for an exception to
the caps, the therapy must be related to one of the listed conditions.
In addition to conditions, there are clinically complex situations
that can justify an automatic exception to the therapy caps for any
condition that necessitates skilled therapy services. As in all
exceptions, the services rendered above the caps must be documented,
covered by Medicare, and medically necessary services. Those complex situations include:
The beneficiary was discharged from a hospital or skilled nursing
facility (SNF) within 30 treatment days of starting this episode of
outpatient therapy. The claim should indicate the date of discharge
and name of hospital or SNF.
The beneficiary has, in addition to another disease or condition
being treated, generalized musculoskeletal conditions or a condition
affecting multiple sites that is not listed as qualifying for an
automatic exception that will have a direct and significant impact on
the rate of recovery.
The beneficiary has a mental or cognitive disorder in addition to
the condition being treated that will have a direct and significant
impact the rate of recovery.
For the above complexities, the provider should include in the
documentation all relevant disorders or conditions and describe the
impact. For example: A sprained ankle does not qualify for exception
by condition, but if the patient also has a dysfunctional wrist on the
opposite side that precludes the use of a cane, it could cause a direct
and significant impact on the patient’s need for skilled physical
therapy, and might cause services in that calendar year to exceed
caps.
The beneficiary requires physical therapy (PT) and speech-language
pathology (SLP) services concurrently. If the combination of the two
services causes the cap to be exceeded for necessary
services, the services are excepted from the PT/SLP cap. There is no effect on the occupational therapy cap.
The beneficiary had a prior episode of outpatient therapy during this calendar year for a different condition.
If services are medically necessary and would be payable under the cap,
an exception is allowed if prior use of services for a different
condition caused the cap to be exceeded and the medically necessary
services to be denied. In cases where the beneficiary was treated in
the same year for the same condition, a written request and contractor
approval is required for use of the KX modifier if the condition does
not qualify for an automatic exception.
The beneficiary requires this treatment in order to return to a
previous place of residence. Document that environment and what is
needed to return. For example: “Patient is progressing (see initial and
current objective measurement scores) and has a good potential for
completing goals for independent use of the toilet which is required for
discharge from the nursing home setting and return to the assisted
living facility where she resided prior to the stroke.”
The beneficiary requires this treatment plan in order to reduce
Activities of Daily Living assistance or Instrumental Activities of
Daily Living assistance to previous levels. Document prior level of
independence and current assistance needs.
The beneficiary indicates he/she does not have access to outpatient
hospital therapy services. List reasons that justify why the patient
cannot obtain necessary services from a hospital outpatient department.
Reasonable justifications include residents of skilled nursing
facilities prevented by consolidated billing from accessing hospital
services, debilitated patients for whom transportation to the hospital
is a physical hardship, or lack of therapy services at hospital in the
beneficiary’s county.
Use of Modifier: When services qualify for
either an automatic or manual exception, provider/suppliers should add a
KX modifier to each line of the claim that contains a service that
exceeds caps. This modifier represents the provider/supplier’s
attestation of medical necessity. Medical records continue to be
subject to review for possible misrepresentation, fraud or patterns of
abuse. If the contractor determines that the provider/supplier has
inappropriately used the modifier, the provider/supplier may be subject
to sanctions resulting from providing inaccurate information on a claim.
Further Information: Further information regarding
automatic exceptions and the process for requesting and documenting
manual exceptions is published on the CMS website at: www.cms.hhs.gov/Manuals/IOM/list.asp#TopOfPage.
The therapy caps are discussed in Pub 100-04, chapter 5, section
10.2, Pub.100-8, chapter 3.4.1.2, and Pub 100-02, chapter 15, section
220.3. Other information concerning the process can be found in
CR4364, at www.cms.hhs.gov/Transmittals/2006Trans/list.asp#TopOfPage.
ATTACHMENT
Diagnosis Codes That Qualify for an Automatic Exception to the Caps
Note: On this table, conditions are represented in normal type and complexities are bold with asterisks.
ICD-9
Description
V43.64
Joint replacement, hip
V43.65
Joint replacement, knee
V43.61
Joint replacement, shoulder
V49.63-49.67
Upper limb amputation status
V49.73-49.77
Lower limb amputation status
250 – 250.93
Diabetes mellitus*
278.01-278.02
Overweight, Obesity, and other hyperalimentation *
290.0-290.4
Dementias*
294.0-294.9
Persistent mental disorders due to contions classified elsewhere*
311
Depressive disorder NEC*
323.0-323.0
Encephalitis, myelitis, and encephalomyelitis*
331.0-331.9
Other cerebral degenerations
332.0-332.1
Parkinson's disease
333.0-333.99
Other extrapyramidal diseases and abnormal movement disorders
334.0-334.9
Spinocerebellar disease
335.0-335.9
Anterior horn cell disease
336.0-336.9
Other diseases of spinal cord
337.20-337.29
Reflex Sympathetic Dystrophy
340
Multiple sclerosis
342.00-342.9
Hemiplegia and Hemiparesis
343.0-343.9
Infantile cerebral palsy
344.00-344.9
Other paralytic syndromes
348.9-348.9
Other conditions of brain
349.0-349.9
Other and unspecified disorders of the nervous system
353-357
Neuropathies
359.0-359.9
Muscular dystrophies and other myopathies
386.0-386.9
Vertiginous syndromes and other disorders of vestibular system*
401.0-401.9
Essential Hypertension*
402.00-402.91
Hypertensive heart disease*
414.00-414.9
Other forms of Chronic Ischemic Heart Disease*
415.0-415.19
Acute pulmonary heart disease*
416.0-416.9
Chronic pulmonary heart disease*
427.0-427.9
Cardiac dysrhythmias*
428.0-428.9
Congestive Heart failure*
430-432.9
Intracranial hemorrhages
433.0-434.9
Occlusion and stenosis of precerebral and cerebral arteries (for occlusion only)
436
Acute, but ill-defined, cerebrovascular disease
437.0-437.9
Other and ill-defined cerebrovascular disease
438.0-438.9
Late effects of cerebrovascular disease
443.0-443.9
Other peripheral vascular disease*
453.0-453.9
Other venous embolism and thrombosis*
457.0-457.1
Postmastectomy lymphedema syndrome and other lymphedema
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