Therapy:
HEED 4 KEY CHANGES TO THERAPY CAPS FOR OUTPATIENTS
Published on Thu Jan 11, 2007
With only a $40 raise, experts weigh in on what will affect you most.
The outpatient therapy cap will go from $1,740 to $1,780 in 2007 for both PT/SLP and OT...quot; but that's not where the changes stop. Get to know these important highlights from the latest exceptions process if you offer Part B therapy.
More and more home health agencies are offering outpatient therapy under Part B to patients who aren't homebound, but they need to understand the therapy caps to avoid furnishing those services for free. By law, the caps apply to Part B therapy services only, not therapy furnished under a home health plan of care. 1. No More Manual Exceptions The Centers for Medicare & Medicaid Services no longer will allow manual exceptions to the therapy caps, CMS says in Dec. 29, 2006 Transmittal 1145. Only the automatic exception process will be available in 2007, according to the memo.
The automatic exception process was the most useful for home health agencies anyway, experts say. (For an overview of both exception processes, see Eli's HCW, Vol. XV, No. 9) 2. Cap Amount Bumps Up Same as last year, CMS Transmittal 1106 issued Nov. 9, 2006 outlines two therapy cap categories: one for physical therapy and speech language pathology, and another for occupational therapy. But CMS raised the therapy cap amount for both categories from $1,740 in 2006 to $1,780 in 2007 (see Eli's HCW, Vol. XV, No. 45).
Details: The 20 percent coinsurance still applies, requiring you to bill the 20 percent balance to secondary insurance or hold the beneficiary responsible for it, says Joanne Byron, president of Health Care Consulting Services in Hickory, NC.
The beneficiary exhausts the cap when the physician fee schedule's allowed amounts are applied to all therapy claims submitted for each respective cap. "This is an annual financial limitation assigned to each beneficiary," Byron adds. "Once the limitation is reached, it is exhausted until the beginning of the next calendar year."
But once the limitation is reached, you have the option of an automatic exceptions process, notes physical therapist Rick Gawenda, director of physical medicine and rehabilitation at Detroit Receiving Hospital.
Remember: For claims with dates of service from Jan. 1 through Dec. 31, 2007, Medicare will apply the caps "in order, according to the dates when the claims were received," the transmittal notes.
3. Multiple Conditions Clarified The original transmittal (855) said that one qualifier for an automatic exception was if a therapy patient was discharged and returned the same year with a second, separate condition.
"But it didn't say what to do if a therapist is treating the patient for one condition while a second condition arises during the treatment for the first condition," Gawenda points [...]
