Therapy Cap: Exceptions
• January 1 - October 1, 2012: an automatic
exception to the therapy cap may be made when
documentation supports the medical necessity of the
services beyond the cap. Providers should use the KX
modifier.
• October 1, 2012 - December 31, 2012: an
automatic exception may be made for claims between
$1880-$3700 (use KX modifier).
• October 1, 2012 - December 31, 2012: Claims
exceeding $3700 in expenditure will be subject to
manual medical review to be paid.
2
2012 Therapy Cap:
Hospitals
• Starting October 1, 2012 the therapy cap with an
exceptions process will apply to Part B SNF,
CORF, ORF, private practices,
Rehabilitation agencies, and Hospital
Outpatient Departments (critical access
hospitals are exempt).
• Hospitals would no longer be subject to the therapy cap
after December 31, 2012 unless Congress extends the
provision in future legislation.
3
2012 Therapy Cap:
Dollars Accrued
• Therapy cap is based on the allowed
charges.
• Medicare Part B will pay 80% of the
allowed charges ($1504.00) and the
beneficiary will be responsible for the
remaining 20% ($376.00).
• MPPR reduction is included in the amount
of the allowed charges.
2012 Therapy Cap:
Dollars Accrued
• C-SNAP uses the Centers for Medicare &
Medicaid Services (CMS) beneficiary
eligibility system to provide our Real-time
Eligibility data.
• http://www.wpsmedicare.com/j5m
acpartb/resources/claims_elig_too
ls/csnap/
Therapy Evaluations
• Therapy evaluations after the therapy
caps are reached to determine if the
patient needs therapy services would be
exempt from the cap. (97001 (PT
evaluation) & 97002 (PT reevaluation).
Therapy Cap:
Manual Medical Review
• Phase I providers: Subject to manual medical review from
October 1‐December 31, 2012.
• Phase II providers: Subject to manual medical review from
November 1‐December 31, 2012.
• Phase III providers: Subject to manual medical review from
December 1‐December 31, 2012.
• List of NPIs and phases to which they are assigned is
available at:
https://data.cms.gov/dataset/Therapy-Provider-PhaseInformation/ucun-6i4t
Therapy Cap:
Manual Medical Review
• PROVIDERS SHOULD NOT SEND
IN CLAIMS FOR PRE-APPROVAL
BEFORE THE SCHEDULED
BEGIN DATE FOR EACH PHASE
(see next slide for dates)
Phase
Pre-approval Start
Date
Service Start Date
Phase I
September 16, 2012
October 1, 2012
Phase II
October 17, 2012
November 1, 2012
Phase III
November 16, 2012
December 1, 2012
Therapy Cap:
Manual Medical Review
• PROVIDERS MUST SUBMIT
REQUEST ON CORRECT FORM
(wrong form = no review)
• PROVIDERS SHOULD CONTACT
THEIR REPSECTIVE MAC OR
LEGACY TO DETERMINE THE
APPROPRIATE FORM
Therapy CAP Exception Preapproval Request
PART A
(BILL ON UB04 FORM)
WPS – Medicare
Attention: Medical Review Department
3333 Farnam Street, Suite 600
Omaha, NE 68131
**WPS only accepts paper submissions mailed to the above address.
Beneficiary Last Name ________________First Name _________ Middle initial _____
HIC #_______________________ Beneficiary Date of Birth_____________________
Ordering Provider Name ________________________________________________
Ordering Provider PTAN/NPI # ____________________________________________
Ordering Provider Address ________________________________________________
City _____________________________State ________ Zip Code ________________
Contact Phone # ________________________________________________________
Performing Provider Name _______________________________________________
Performing Provider PTAN/NPI # ___________________________________________
Performing Provider Address______________________________________________
City _____________________________State ________ Zip Code________________
Contact Phone # ________________________________________________________
Number of treatment days requested: PT ________________________
Number of treatment days requested: OT ________________________
Number of treatment days requested: SLP _______________________
Expected date range of services: PT ____________________________
Expected date range of services: OT ____________________________
Expected date range of services: SLP ___________________________
Requestor:_________________________________________________
Date of submission:__________________________________________
Phone # and Email address____________________________________
This Cover Sheet must be submitted to process preapproval request
Therapy CAP Exception Preapproval Request
PART A
(BILL ON UB04 FORM)
This Cover Sheet and the following requested information and documentation must be submitted with the
preapproval request:

Justification for the extended treatment days

Evaluation/Reevaluation form to include:

o
Physician order
o
Signed and dated certification by physician
o
Date of evaluation
o
Start of care date
o
Medical diagnosis & Treatment diagnosis
o
Onset date
o
Current level of function
o
Prior level of function
o
Treatment plan with long and short term goals
Previous Therapy administered to include:
o
Date
o
Diagnosis for treatment
o
Modalities administered

Three months of progress reports and treatment notes detailing service provided for each date of
service billed

Grid reflecting service/HCPCS provided

Actual minutes provided to support each timed service/HCPCS provided

Advance Beneficiary Notice (if applicable)
Request for advance preapproval for therapy services above $3,700
PART B (BILL ON HCFA 1500 FORM)
Please submit the following information to:
WPS Medicare
Attention: Medical Review Department
1717 West Broadway
Madison, WI 53713
**WPS only accepts paper submissions mailed to the above address.
Beneficiary Last Name ________________First Name_________ Middle initial______
HIC #_______________________ Beneficiary Date of Birth_____________________
Ordering Provider Name ____________________________
Ordering Provider PTAN/NPI #____________________
Ordering Provider Address ________________________________________________
City _____________________________State ________ Zip Code _________________
Contact Phone # __________________
Performing Provider Name ____________________________
Performing Provider PTAN/NPI #____________________
Performing Provider Address ______________________________________________
City _____________________________State ________ Zip Code ________________
Contact Phone # __________________
Number of treatment days requested: PT ____________
Number of treatment days requested: OT ____________
Number of treatment days requested: SLP ____________
Expected date range of services: PT __________________
Expected date range of services: OT __________________
Expected date range of services: SLP __________________
Requestor: _________________________________________________
Date of submission: __________________________________________
Phone # and Email address____________________________________
Request for advance preapproval for therapy services above $3,700
PART B
This Cover Sheet must be submitted to process preapproval request
This Cover Sheet and the following requested information and documentation must be submitted with the
preapproval request:

Documentation that supports the individual is under the care of a physician (such as an order or referral for
additional therapy services).

Initial evaluation and any re-evaluations to support medical necessity.

Initial certification and any subsequent recertification of the Plan of Care.

Any documentation supporting medical necessity for the extended services.

A Plan of Care (signed and dated) established by a physician/nonphysician practitioner (NPP) or by the therapist
providing the services. The plan of care must contain:

o
Diagnosis
o
Objective and measurable treatment goals; and
o
Type, amount, duration and frequency of therapy services
Treatment progress notes for three (3) months prior to the requested dates of extended services which include:
o
Date of treatment;
o
Identification of each specific intervention/modality provided and billed, for both timed and untimed codes,
in language that can be compared with the billing on the claim to verify correct coding;
o
Total timed code treatment minutes and total treatment time in minutes. Total treatment time
includes the minutes for timed code treatment and untimed code treatment. Total treatment time does not
include time for services that are not billable (e.g. rest periods); and
o
Signature and professional identification of the qualified professional who furnished or supervised the
services and a list of each person who contributed to that treatment.

Therapy treatment logs.

All flow sheets pertinent to therapy provided.

Qualifications of personnel providing services.

Therapy discharge notes (if applicable).

Information on any special devices being used for therapy services.

Written/telephone physician orders.

Signature key for all flow sheets.
A key for non-standard abbreviations.
Therapy Cap:
Manual Medical Review
• FORM MUST BE MAILED
• DO NOT FAX FORM
• RECOMMEND CERTIFIED MAIL
• WPS WILL NOT TRACK IF IT WAS
RECIEVIED or NOT RECIEVED
Therapy Cap:
Manual Medical Review
• Medicare Administrative Contractors (MAC) will have 10 business
days to make decisions regarding whether services will
be approved over the $3700 amount. If a provider request is not
reviewed by MAC within 10 business days, claims beyond
the $3700 threshold will be approved.
• Advanced approval will allow an additional 20 treatment days
beyond the $3700 amount.
• Provider will use modifier on claim form to indicate advance
approval given.
• Advanced approval does not guarantee payment.
– Retrospective review may still be performed.
– There is an APPEAL PROCESS for “Retrospective Review”
– NO APPEAL PROCESS for Manual Review
Therapy Cap:
Manual Medical Review
• If a provider does not request advanced approval
prior to providing services over $3700, payment
for the claims will stop and a request for
medical records will be sent to the
provider.
• The provider will be subject to prepayment review
for those claims and the time frame for review will
be approximately 60 days.
Part A (facilities) Mail To:
WPS Medicare Attention: MR Department
3333 Farnam St., Suite 600
Omaha, NE 68131
J5 / J8 Part B (practitioners) Mail To:
WPS Medicare Attention: MR Department
1717 West Broadway
Madison, WI 53713
Legacy Part B (practitioners) Mail To:
WPS Medicare Attention: MR Department
8120 Penn Ave S, Suite 200
Bloomington, MN 55431
Therapy Cap:
Manual Medical Review
• There is NO APPEAL PROCESS with
the Manual Review (must submit another
review)
Therapy Cap: Example
• Patient A receives therapy services at a SNF (Part B)
from January 15, 2012-April 20, 2012 and accrues
$3800.00 toward the therapy cap.
• Patient A is discharged from the SNF and later goes to
an outpatient hospital department for therapy on October
15, 2012.
• The hospital would need to request manual medical
review to get coverage for these services because the
patient has already exceeded the $3700 threshold.
20
Therapy Cap: Example
• Patient A receives therapy services from an outpatient
hospital from February 15-May 15, 2012 and accrues $3800
in therapy services.
• Patient A goes to a private practice for services on September
20 until November 15. Private practice submits the claim on
September 20 for payment and the common working file
reflects $0 toward the cap.
•
On October 1, the $3800 from the hospital therapy would be
added to the common working file; for dates of service
provided to patient A after October 1 the provider would need
to seek advanced approval (if a phase I provider).
Therapy Cap Example
• Patient A received $4000 of services from a hospital stay
from January 15—May 15, 2012.
• From July 22, 2012 –August 25, 2012 patient A received
services from a private practice.
• The private practice would not need to submit the KX
modifier or submit a request for advanced approval as
Patient A was discharged prior to October 1, 2012.
Therapy Cap Example
• “A beneficiary was in a skilled nursing facility (SNF) and exhausted
their SNF benefit days under Part A.
• The beneficiary continued to receive therapy services under Part B
totaling $3,600 (all dates of service before 10/1/2012).
• The beneficiary was then discharged from the SNF and received
therapy services from an independently practicing PT totaling
$1,800.
• The independent PT billed in November 2012 for services provided
after 10/1/2012.
Therapy Cap Example
• The MAC received the claims and processed them. After these
claims were processed the MAC received the SNF Part B claims
totaling $3,600 and processed them.
• Had these claims been received in advance of the independent PT
services the independent PT would have been required to have the
services approved in advance.
• In circumstances such as the example above the contractor is not
required to perform post payment review on the $1,800 provided by
the independent therapist. “
Notification to
Beneficiaries
• Beneficiaries who have received $1700 or more
of therapy services in 2012 received letters in
September 2012 providing them information
about their potential financial liability for services
over the therapy cap amount.
• APTA provided a document for beneficiaries to
provide info on cap.
http://www.moveforwardpt.com/Resources/Advo
cacy.aspx
Therapy Cap:
Collecting Out of Pocket
• If a patient does not qualify for an exception, the provider
can collect out of pocket payment from the beneficiary.
• It is advisable to give the beneficiary an Advanced
Beneficiary Notice (ABN) if Collecting Out of Pocket.
Revised ABN form (Form-R-131) available on the CMS
website at: https://www.cms.gov/BNI/02_ABN.asp
26
Therapy Cap:
Collecting Out of Pocket
• Provider can determine the amount of
payment to collect from the patient; it does
not have to be the fee schedule amount.
• Providers should avoid deep discounts or
providing services for free as that could
violate anti-kickback statutes.
Therapy Cap:
Collecting Out of Pocket
• If provider would like a denial from Medicare in order
to bill a secondary insurer after the therapy cap
amount is exceeded, the provider could submit claim
with a modifier:
• GX Modifier:
• Notice of Liability Issued, Voluntary Under Payer Policy.
• Report this modifier only to indicate that a voluntary ABN was
issued for services that are not covered.
• Medicare will automatically reject claims that have the –GX
modifier applied to any covered charges.
• GY modifier:
• Notice of Liability Not Issued, Not Required Under Payer
Policy. This modifier is used to obtain a denial on a non covered
service. Use this modifier to notify Medicare that you know this
service is excluded.
APTA RESOURCES
• APTA has developed a Medicare Therapy Cap
Resources website. This website compiles relevant
information available from APTA and CMS in one place.
• You can view the website by clicking here or by going to
APTA’s homepage and clicking Learn More on the
Medicare marquee. Please share this information with your
colleagues and staff
• Questions regarding the therapy cap may also be emailed directly to
CMS at therapycapreview@cms.hhs.gov.

On July 6, 2012 the Centers for Medicare and
Medicaid Services (CMS) released the proposed 2013
Medicare physician fee schedule rule that updates
2013 payment amounts and revises other payment
policies.
◦ http://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/PhysicianFeeSched/PFS-Federal-RegulationNotices-Items/CMS-1590-P.html

CMS will publish a final rule by November 1, 2012
which will become effective for services furnished
during calendar year 2013.

KanCare benefit packages outlined (By Dave
Ranney; Wednesday, September 26, 2012)
◦ Comparison of benefit packages offered by KanCare
MCOs

A brief outline of the AFFORDABLE CARE ACT
(ObamaCare) can be accessed at:
◦ http://en.wikipedia.org/wiki/Patient_Protection
_and_Affordable_Care_Act

TRICARE WILL NOT reimburse for services
furnished by physical therapist assistants that are
provided in a:
◦ Physical therapy private practice
◦ Freestanding clinic
◦ Home care agency
◦ Comprehensive outpatient rehabilitation
facility (CORF)
WILL reimburse for
services furnished by a physical
therapist assistant in a:
 TRICARE
 Hospital
 Skilled
nursing facility

Kansas Department of Labor: Division of
Workers' Compensation

Kansas WC contacts:
http://www.dol.ks.gov/WorkComp/Default.aspx