by Ingrida Lusis
The federal Tax Relief and Health Care Act of 2006 extended Medicare outpatient therapy cap exceptions for all outpatient speech-language, physical, and occupational therapy services provided in 2007.
The exceptions process allows Medicare beneficiaries to continue to receive medically necessary outpatient services after the cost of services exceeds the Medicare-allowed ceilings. The outpatient therapy financial limitations for 2007 are $1,780 for combined speech-language pathology and physical therapy services, and a separate $1,780 for occupational therapy services. The Centers for Medicare and Medicaid Services (CMS) issued detailed instructions on implementation of the exceptions process on Dec. 29, 2006; they can be found at www.cms.hhs.gov/transmittals/downloads/R1145CP.pdf [PDF - 732KB].
Q: Will there be any changes to the exceptions process for 2007?
Yes. CMS will no longer accept manual requests; clinicians may request an exception only through the automatic process and the use of the KX modifier. CMS has identified conditions and complexities, using ICD-9 codes, that may exceed the cap. However, CMS also has placed a greater emphasis on clinicians' professional judgment by allowing them to submit automatic exceptions for other diagnoses and complexities, as long as the clinician has documented justification for the need for services that exceed the therapy cap limitation.
Q: Will the KX modifier continue to be used to signal an exception?
Yes. When the beneficiary qualifies for a therapy cap exception, the KX modifier is required with the CPT/HCPCS code on the claim form. The use of the KX modifier signals to CMS that services are medically necessary and that justification of the need for services above the cap is documented in the medical record.
When submitting a claim for speech-language pathology services that includes at least one line that exceeds the cap, clinicians should use the KX modifier on all of the lines on that claim that refer to physical therapy and speech-language pathology services, regardless of whether the other services exceed the cap.
In addition to the KX modifier, the GN modifier that identifies speech-language pathology services still is required; they may be listed in any order (e.g., GN, KX 92507).
Q: How should an SLP document the need for additional services above the cap?
Documentation is key to ensuring compliance with the exceptions process. CMS has tightened its documentation requirements to ensure that services being provided are medically necessary, and suggests the use of ASHA's National Outcomes Measurement System (NOMS) as a method for documenting a patient's functional improvement and justifying services above the caps.
In general, documentation must include the evaluation and plan of care, progress notes, treatment notes, and the discharge note. Although not required, CMS strongly encourages clinicians to include other information that demonstrates the patient's progress toward treatment goals. Speech-language pathologists should ensure that their documentation is legible, relevant, and sufficient to justify the services being billed.
Ingrida Lusis is director of health care regulatory advocacy. Contact her at ilusis@asha.org or 800-498-2071, ext. 4482. More information on the therapy cap exceptions process and CMS documentation requirements can be found on ASHA's Reimbursement Web site.