The Parkinson’s Action Network and Muhammad Ali Parkinson’s Center  at the Barrow Neurological Institute have come together to better explain Medicare therapy caps and the “exceptions process” to your physical therapists and other providers. Please help us spread this important information by sharing this Q&A with your physical therapists and other providers.
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Medicare Therapy Caps and the “Exceptions Process” Available
to the Parkinson’s Community
Do you have patients with Parkinson’s who are on Medicare? Did you know there is an exceptions process that removes the annual $1,900 Medicare therapy cap for already-approved medically necessary physical, and occupational, and speech-language therapy?
The Parkinson’s Action Network and Muhammad Ali Parkinson Center at the Barrow Neurological Institute have compiled a short Q&A below for physical therapists and other providers to better understand (and help their patients navigate) the Medicare therapy caps exceptions process.
Brief Background: Medicare Therapy Caps
In 1997, Congress created limits, or caps, on the amount of outpatient physical, occupational, and speech-language therapy a Medicare beneficiary can receive in a calendar year.
There is a combined $1,900 cap for physical therapy and speech-language therapy, and a separate $1,900 cap for occupational therapy in 2013. Once these levels are reached, beneficiaries who require additional services in the calendar year are responsible for 100 percent of the cost of those services, or must forego the care altogether.
Why does the Parkinson’s community care about Medicare therapy caps?
Medicare therapy caps place an unnecessary burden on people with Parkinson’s and other diseases. According to the American Physical Therapy Association, one-third of people with Parkinson’s exceed the therapy caps each year.
What is the Medicare therapy caps exceptions process?
To serve Medicare beneficiaries who need therapy services beyond the cap, in 2006 Congress created an exceptions process for services deemed medically necessary. The exceptions process is applicable for therapy services in excess of the cap amount delivered any time during the calendar year.
Are Medicare therapy caps something I should talk about with my patients both at intake and at the beginning of the calendar year, so we can plan their care and benefits together and prepare for the therapy caps exceptions process?
Absolutely. The discussion will avoid any confusion about therapy treatment plans as well as ensure that the patient is well informed about the options regarding their treatment plan.
Why is coding of medical necessity important so that patients can continue to receive physical or other therapy?
Appropriate coding and documentation is important to ensure patients can continue to receive therapy. When a patient reaches the annual therapy cap level of $1,900, if care continues to be medically necessary, the therapist must apply a KX modifier to the therapy code to show the use of the therapy cap exceptions process. Documentation must also be detailed and support the medical necessity of continuing therapy. Documentation to support medical necessity also is important when a patient reaches $3,700 in annual spending as Medicare will review each claim above this threshold to determine if care can continue. The documentation should indicate why the patient requires continued skilled therapy as the absence of this information may result in Medicare’s decision to deny claims for these services.
If my patient is going to exceed the cap, how does the therapist apply for the exceptions process?
In 2013, there are two exceptions processes: an automatic exception process (at $1,900) and a manual medical review process (at $3,700).
The automatic exceptions process does not require submission of documentation. Medicare beneficiaries will be automatically exempted from the therapy cap and providers will not be required to submit documentation if the patient meets the criteria for an automatic exception. Additional documentation shall be submitted if a request is made.
Manual Medical Review will be subject to documentation review.
For detailed, specific information on how to utilize the exceptions processes, please see the full FAQ on American Physical Therapy Association website:
TAKE ACTION: Help fight for change!
As a physical therapist, your voice matters on many issues important to the Parkinson’s community – including Medicare. The Medicare therapy caps exceptions process is temporary and must be reauthorized by Congress every year. In January 2013 Congress passed, and the president signed, a continuation of the exceptions process. This extension expires December 31, 2013. The Parkinson’s Action Network and many of its colleague organizations support a full, permanent repeal of the Medicare therapy caps. You can help us make this happen!
Click here  to contact your Members of Congress and ask them to co-sponsor the Medicare Access to Rehabilitation Services Act of 2013 (H.R. 713/S. 367), which would permanently repeal the burdensome therapy caps.
Date originally posted: August 16, 2013.