Orthopedic Coding Alert

Cap exceptions go fully automatic this year As many orthopedic practices know, the -therapy cap- limits Medicare beneficiaries to a combined physical therapy (PT) and speech language pathology (SLP) maximum of $1,780 in annual benefits. Medicare patients face a separate $1,780 cap for occupational therapy (OT) services as well. But that's not where the changes stop. Get to know these important highlights from the latest exceptions process procedures. 1. Cap Amount Bumps Up
 
Unlike last year, when the cap amount was $1,740, you-ll notice that the therapy cap amount increased to $1,780 this year. The 20 percent coinsurance still applies, requiring you to bill the 20 percent balance to secondary insurance or hold the beneficiary responsible for it.

The beneficiary exhausts the cap when the physician fee schedule's allowed amounts are applied to all therapy claims submitted for each respective cap.
Once the limit is reached, however, the patient may qualify for an automatic exception.

2. Get to Know Automatic Exceptions Process CMS previously allowed PT providers to apply for a manual exception to the cap, or to be subject to an automatic exception. But on Dec. 29, 2006, CMS released Transmittal 1145 mandating that the exceptions process would now be -entirely automatic- starting Jan. 1, 2007.

If the therapist truly thinks 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., as part of a manual exceptions process. Now, your documentation will just have to justify the condition that qualifies for exceptions. 3. 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.

4. Determine Which Conditions Qualify for Exception CMS will allow automatic exceptions for certain conditions or complexities without a written request. Following is a sampling of diagnoses that will automatically warrant exceptions:

- Joint replacement (V43.61-V43.69)

- Aftercare for healing pathologic or traumatic fracture (V54.10-V54.29)

- Contracture of joint; multiple sites (718.49)

- Difficulty in walking (719.7)

- Gait abnormality (781.2)

- Lack of coordination (781.3)

- Vertebral column fractures (806.00-806.9)

- Clavicle fracture (810.11-810.13)

- Scapula fracture (811.00-811.19)

- Humerus fracture (812.00-812.59)

- Radius/ulna fracture (813.00-813.93)

- Fracture of femur neck (820.00-820.9)

- Dislocations (830.0-839.9).
 
When you submit claims for services that qualify for the cap exception, you should append modifier KX (Specific required documentation on file) to the procedure codes. This modifier tells the contractor that the services provided qualify for an automatic exception, and it represents the provider-s/supplier's attestation of medical necessity of the therapy services. 5. Make Sure Patient Meets Code Requirements [...]