HCR: Therapy Caps Exception Extended

On March 23, President Obama signed into law the Patient Protection and Affordable Care Act (HR 3590), which extends the exceptions process for outpatient therapy caps (see section 3103). Outpatient therapy service providers may continue to submit claims with modifier KX Requirements specified in the medical policy have been met, when an exception is appropriate, for services furnished on or after Jan. 1, through Dec. 31.

The therapy caps are determined on a calendar year basis, so all patients began a new cap year on Jan. 1. For physical therapy (PT) and speech language pathology services combined, the limit on incurred expenses is $1,860. For occupational therapy (OT) services, the limit is $1,860. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached.

TrailBlazer Health offers the following guidance for handling requests to add the modifier KX:

If modifier KX needs to be added to a service that previously processed without the modifier, the services may either be refiled as a new claim or a redetermination may be requested.

Claim Issue

The entire claim is denied due to the cap. The patient meets the automatic exception.

Solution

Refile the claim with the appropriate PT/OT modifier (GN, GO, GP) and modifier KX. A redetermination request is not needed. The patient’s medical record should reflect the automatic exception. Documentation should not be submitted with the claim.

Claim Issue

Denied and allowed services due to the cap are on the same claim. The patient meets the automatic exception.

Solution

Refile only the denied services with the appropriate PT/OT modifier (GN, GO, GP) and modifier KX. (If the entire claim is refiled, the allowed services will deny as a duplicate.) A redetermination request is not needed. The patient’s medical record should reflect the automatic exception. Documentation should not be submitted with the claim.

Claim Issue

One line item is allowed incorrectly due to the cap limitation.

Example: Code 97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility allowed $5 and it should have allowed $10. The therapy cap limitation was met on this line. The patient meets the automatic exception.

Solution

A redetermination will need to be requested by submitting a Part B Redetermination Request Form.

Effective March 2, TrailBlazer will no longer handle requests to add modifier KX as a reopening. The contractor’s Telephone Reopening line will no longer assist callers with modifier KX reopening requests. Written reopening requests for the addition of modifier KX will be dismissed.

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