Therapy cap limits were reintroduced on January 1, 2006. However, Congress recently enacted exceptions to the dollar limitations when additional therapy is determined to be medically necessary. This update provides the ability to submit claims when the exception process is applicable.

The Exception Process:

Exception are allowed for medically necessary services. If a resident is not subject to the cap limitations that fact should be indicated in the Update Additional UB92 Information screen [CC, 14, 5].

The Update Additional UB92 Information screen appears below:

                       Additional UB92 Billing Information

 Resident: _____________________       
                                      Cumulative  Do NOT
      Onset     PlanEstb   1stTreat    Visits     Bill After
 PT  ▬▬▬▬▬▬▬▬▬▬ ▬▬▬▬▬▬▬▬▬▬ ▬▬▬▬▬▬▬▬▬▬  ▬▬▬▬       ▬▬▬▬▬▬▬▬▬▬
 OT  ▬▬▬▬▬▬▬▬▬▬ ▬▬▬▬▬▬▬▬▬▬ ▬▬▬▬▬▬▬▬▬▬  ▬▬▬▬       ▬▬▬▬▬▬▬▬▬▬
 SP  ▬▬▬▬▬▬▬▬▬▬ ▬▬▬▬▬▬▬▬▬▬ ▬▬▬▬▬▬▬▬▬▬  ▬▬▬▬       ▬▬▬▬▬▬▬▬▬▬

  Eligible Medicare       Part 'B'
  'A':   'B':   'D':      . Coverage Start Date: ▬▬▬▬▬▬▬▬▬▬
                          . Coverage End Date  : ▬▬▬▬▬▬▬▬▬▬
                          . HMO Bill Type to Bill Part 'B': ▬▬
  Part 'D'                Part 'B' Therapy Limits Exceptions
  . RX Plan:              . PT Y OT Y  From Date  __________ To Date __________
                          Dialysis Center
                          . Override Condition Code: ▬▬
                          . Code '74' Dates: ▬▬▬▬▬▬▬▬▬▬ - ▬▬▬▬▬▬▬▬▬▬
                          Medicare Rates
                          . Use Medicare Adjusted Rate: ▬

Under the section titled, 'Part B Therapy Limits Exceptions enter the exception for that resident as follows:

If the exception is for PT then at PT type 'Y'. If it is for OT then at OT type 'Y'. (In general, the exception is usually for both PT and OT.)

A range of dates can also be specified for the exception. If the date range is left blank then the exception process will apply from January 1, 2006 and onward.

When posting Therapy Charges for those residents that are indicated as being exceptions to the caps, the Post Ancillary Charges program 'POSTANCL' [AR,2,2] will cause the charges to post without being written off, and will insert a modifier code of 'KX' as specified by Medicare.

CMS has also stated that they will treat as exceptions from the cap limits the following therapy evaluation procedures after the therapy caps are reached:

92506, 92597, 92607, 92708, 92610, 92611, 92612, 92614, 96616, 96105, 97001, 97002, 97003, 97004.

The Post Ancillary program has been adjusted to comply with this rule.

Be sure to review the printouts before posting.

Note: The following areas have not been addressed in this update: 1) Rebilling January '06 charges that have already been posted and that exceeded the therapy cap, 2) The ability to handle additional modifiers besides 'GP', 'GO', and 'GN' where the 'KX' modifier is applicable for PT, OT or Speech charges.

If you have any additional questions please feel free to call client service at (718) 338-2400.

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