Warning: You can't appeal denied exception requests.
If your Part B therapy program can't qualify a patient for a therapy cap exception under the automatic process, you may need to try a more work-intensive option.
The significantly less burdensome automatic process covers many patient conditions, so find out first if your patient qualifies before resorting to a manual process, experts recommend. Under the manual process, you must submit a written request to your Medicare Part B carrier explaining the need for an exception. Then, the contractor will decide to grant or deny the exception.
Your request must contain specific documentation, including a justification for the request, the Centers for Medicare & Medicaid Services says in Feb. 15 Transmittal No. 140. Also, you may not request more than 15 treatment days of service beyond the cap, but you can send another request for an exception after you determine that the treatment will extend beyond your contractor's approved amount.
Good idea: Mark your calendar because Medicare contractors have 10 business days to respond to your letter with a grant or denial or CMS will automatically deem your requested services medically necessary. Get It Right The First Time Your documentation must be compelling the first time around. That's because unlike with regular claims processing, you may not appeal a denied exception request, warns the American Physical Therapy Association's Dave Mason
To avoid this trap, be sure you can justify the therapy in the medical record, advises Leslie Stein Lloyd, director of reimbursement and regulatory policy for the American Occupational Therapy Association.
Example: If your patient has a fractured humerus (812.00), you need to report the code and document range of motion deficits, strength deficits and difficulties with activities of daily living (ADLs), says physical therapist Rick Gawenda, director of physical medicine & rehabilitation at Detroit Receiving Hospital in Detroit, MI.
Don't miss: Documenting the subjective information such as previous therapies can give you a head start with an automatic or manual exception, Gawenda says. For example, noting that the patient was recently discharged from a skilled nursing facility or that he's also receiving speech-language services are going to become important now that the exception appeal is on the line.
For guidance in outpatient therapy documentation for the exceptions process, home care providers can look to Feb. 15 Transmittal No. 47. For instance, you must use new methods for documenting your evaluation and certified plan of care, the physician certification, progress reports and treatment encounter notes.
Note: Transmittal No. 140 is at
www.cms.hhs.gov/transmittals/downloads/R140PI.pdf and Transmittal No. 47 is at
www.cms.hhs.gov/transmittals/downloads/R47BP.pdf.
