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Legislation>>Taking the Guess Work Out of Medicare Cap - 1/3/2007

After many years of delayed implementation due to multiple moratoriums, the Medicare Cap on outpatient therapy services went into effect January 1, 2006.

Congress recognized that the "Cap" could be detrimental to the health of many Medicare beneficiaries and passed a law mandating that Medicare (CMS) put an exception process in place and have it retro-active to January 1, 2006. The exception process is designed to allow for continuation of medically necessary services.

Below provides highlights:

  • CMS intends that most patients who require medically necessary services that would exceed the "Cap" would quality via an automatic exception which is identified by diagnosis. Please our web-site for a complete listing of diagnostic codes (ICD-9) that qualify as automatic exception.
  • Most neurological and orthopedic conditions that would most likely require services beyond the "Cap" are listed as automatic exceptions.
  • Therapists can apply for a manual exceptions for patient's whose diagnosis does not qualify for an automatic exception.
  • There is no more paperwork for the patient or their referring physicians for either the automatic or manual exception process. The therapy provider is responsible for communicating to Medicare the need for the automatic exceptions as well as provide the needed documents to apply for a manual exception.
  • The exception process does allow for therapy services if a patient has multiple health issues within the same year. For example, if a patient had services for a shoulder injury in March , they would be allowed to receive medically necessary services for a total hip replacement in September.

If you have any questions in regards to the "Medicare Cap, please see our web-site for "Frequently Asked Questions" (FAQ) as well as links to the CMS web-site and other resources. Feel free to call us at 593-2610.

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