On November 9, 2006, the Centers for Medicare & Medicaid Services (CMS) issued a Med-Learn Matters provider education article and Medicare program transmittals that clarify aspects of the outpatient therapy cap exceptions process.
The provider education article describes the background of the outpatient therapy cap, beginning with the Balanced Budget Act of 1997; reviews the automatic and manual procedures involved in the cap exceptions process applicable to 2006; and clarifies questions that providers have asked about the exceptions process implementation, earlier this year.
Of particular interest, CMS clarifies that Medicare will interpret a referral, order, or plan of care dated after the date of an evaluation, as certification of the plan to evaluate the beneficiary when only an evaluation was performed. Medicare does not require that a plan, order, or referral be written before evaluation.
In addition, CMS clarifies that when a patient is being treated under the care of two physicians for separate conditions, Medicare must accept as appropriate documentation either: (1) a combined plan of care certified by one of the physicians/non-physician practitioners (NPPs), or (2) two separate plans of care certified by separate physicians/NPPs.
The Medicare transmittals correct errors in the list of conditions and complexities for which automatic exceptions are allowed. The transmittals also announce the therapy cap amount that will be effective from January 1, 2007-December 31, 2007. The therapy cap amount will be $1,780 per beneficiary for occupational therapy services (and $1,780 for physical therapy and speech-language pathology services combined).
Occupational therapy practitioners should be aware that a request for a therapy cap exception will be accepted for calendar year 2006 dates of service; however, no cap exceptions process is currently in place for 2007. AOTA lobbyists are working vigorously with members of Congress to secure passage of legislation extending the cap exceptions process.
AOTA encourages you to contact your members of Congress and request that they act to extend the exceptions process. To write your member, you can access an easy-to-use form on the Legislative Action Center at AOTA's Web site. Stay tuned to the Legislative Action Center for updates.
For more information, see the Med-Learn Matters article MM 5271-Outpatient Therapy Cap Exceptions Clarifications (which also provides links to the Medicare Manual program transmittals discussed above).