Eli's Rehab Report

Second Injury May Justify an Exception

Question: I'm treating a Medicare patient for condition A, which is on the automatic exception list and for which the cap has been met and modifier KX used. If she then suffers a second injury and needs treatment for condition B, which is not on the exceptions list, do her benefits start at zero again for this second, different condition?


Michigan Subscriber
 

Answer: This scenario describes a clinically complex situation that justifies the patient for an automatic exception to the therapy caps. CMS addressed this specific scenario in Claims Processing Manual 104-5 10.2.C.4 (www.cms.hhs.gov/manuals/downloads/clm104c05.pdf).

CMS states, "The beneficiary had a prior episode of outpatient therapy during this calendar year for a different condition. If services are medically necessary and would be payable under the cap, an exception is allowed if prior use of services for a condition caused the cap to be exceeded and the medically necessary services to be denied."

You should append modifier KX (Specific required documentation on file) to all services provided during the second condition's treatment that exceeded the therapy cap.