MDS Alert

Don’t wait until the second progress report to reevaluate medical necessity.

There are a variety of legitimate reasons why a patient may need to exceed the therapy cap, but with the mounting scrutiny of therapy billing, you have to be more careful than ever when you use the therapy cap exception. Here are some expert tips from a Sept. 8 blog posting by Nancy Beckley, MS, MBA, CHC of Nancy Beckley & Associates LLC:

1. Document effectively: “Any diagnosis can qualify for therapy over the cap,” Beckley noted. “The devil is in the details of the documentation, and it starts with the evaluation.” Documentation should be clear and identify the need for a therapy program that may require more visits, a different approach to therapy, more frequent reevaluations, or even a skilled maintenance program.

During the initial evaluation, the therapist should document the complexities and comorbidities present, and how they will affect the care plan and the progress that the patient will make, Beckley instructed. “Therapists are often good at identifying the complexities and comorbidities (especially in the presence of EMR prompts to do so), but often fail to link them to their predicted impact on the course of therapy.”

2. Consider these factors: In deciding whether to use the therapy cap exception, CMS advises you to consider whether the services are appropriate to:

• The patient’s condition, including the diagnosis, complexities, and severity;
• The services provided, including their type, frequency, and duration;
• The interaction of current active conditions and complexities that directly and significantly influence the treatment such that it causes services to exceed caps.

3. Ask yourself: During the next 10 visits following the initial evaluation, keep track of treatment sessions on the way to the progress report, Beckley advised. Also, during these visits ask yourself:

• Am I continually reassessing the patient?
• Am I updating objective tests and measures?
• Am I progressing the patient in the treatment session and in the home exercise program?
• Am I noting the patient’s response to therapy and their active participation in their HEP?

4. Demonstrate medical necessity: “At the 10^th visit your progress report should demonstrate the medical necessity for continued care, and if not, therapy should be wrapped up and the patient discharged,” Beckley noted. “If this first progress report doesn’t demonstrate medical necessity for continued care, it likely won’t by the second progress report — the point when the patient is in all probability over the therapy cap.”

Resource: For more information on billing for therapy over the cap, check out CMS’s guidance at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf.