Orthopedic Coding Alert

Question: I recently learned that Medicare will let some patients exceed the $1,740 therapy cap and that these exceptions will be automatic for some diagnoses. Do we need to file anything special to collect for our PT's services over and above the cap?


California Subscriber
Answer: Effective Jan. 1, Medicare carriers will allow exceptions for patients who exceed the cap, if the patients have certain diagnoses or -medical complexities,- according to a Medicare Fact Sheet.

Your patient may qualify for an automatic exception if you provide medically necessary PT services for patients with diagnoses listed on Medicare's exceptions list. These diagnoses include, among many others: 
 
- difficulty walking (719.7)
- vertebral column fractures (806.00-806.9)
- clavicle fractures (810.00-810.13)
- scapula fractures (811.00-811.19)
- humerus fractures (812.00-812.59)
- radius and ulna fractures (813.00-813.93)
- femur fractures (820.00-821.39)
- multiple limb/rib fractures (828.0-828.1). In addition, Medicare will allow automatic exceptions for some clinically complex situations regardless of diagnosis. For instance, if the patient had a prior episode of outpatient therapy during the calendar year for a different condition, Medicare will allow the patient to exceed the cap for a new condition.

The caveat is that the PT must provide a service that Medicare covers, the treatment must be medically necessary, and you must append modifier KX (Specific required documentation on file) to the procedure codes. This modifier tells the contractor that the services your PT provided qualify for either an automatic or a manual exception and it represents the providers- or suppliers- attestation of medical necessity of the therapy services.

Manual exceptions: If your patient does not have one of the listed diagnoses or conditions, but your PT or orthopedist feels strongly that the patient requires additional physical therapy over and above the cap limit, you can submit a written request for 15 additional therapy days. Along with your letter, submit your documentation and an explanation of why the patient would benefit from therapy beyond the cap limits.

Note: To read the full CMS Fact Sheet on the cap exceptions, visit the CMS Web site at www.cms.hhs.gov/apps/media/press/release.asp?Counter=1782f.