Medicare Compliance & Reimbursement

Say goodbye to the manual exceptions process -- for now. Right after the Centers for Medicare & Medicaid Services (CMS) released updates to the therapy cap exceptions process last November, the agency turned around a month later and put a new spin on things: the manual exceptions process no longer exists.

On Dec. 29, 2006 CMS released Transmittal 1145 mandating that the exceptions process would instead be "entirely automatic" starting Jan. 1, 2007. Know The Pros And Cons The good news: The automatic process hasn't changed, so you don't need to learn any new steps. Other good news is, if you truly believe a patient requires further skilled therapy and that the patient will be able to show significant improvements, you no longer have to go through all the work of submitting records, writing a justification letter, etc., points out Rick Gawenda, PT, director of physical medicine and rehabilitation at Detroit Receiving Hospital.

The bad news: "This puts more onus on the therapy provider to make sure the documentation is there to support his or her reasoning for saying the patient qualifies for an automatic exception," Gawenda adds. But that's exactly why CMS released Transmittal 63 along with the therapy cap transmittal: really to spell out what therapists need to include in their documentation, he explains. Automatic-Only Could Be Temporary The reason CMS nixed this manual exceptions process this year is that not many therapy providers appeared to be using it. If the agency finds that therapists really need the manual process, however, CMS might bring it back.

"We're still trying to inquire of our members how often they used the manual exceptions process and whether the automatic exceptions process has been enough to satisfy their needs," says Chris Metzler, chief public affairs officer for the American Occupational Therapy Association (AOTA).

For now: Take another look at the latest list of acceptable ICD-9 codes for the automatic exception. Because it did away with the manual process, CMS updated the ICD-9s and complexities to a more comprehensive list that will hopefully cover much of what the manual process used to cover.

To see the full transmittal and the new list of ICD-9s, visit www.cms.hhs.gov/transmittals/downloads/R1145CP.pdf.