CMS nixes exceptions process for Part B therapy caps.

CMS closed out 2006 by releasing two transmittals that will affect skilled nursing facility (SNF) professionals in 2007. On December 29, it released Transmittal 63 and Transmittal 1145, both of which were required to be implemented by January 29, 2007.

Transmittal 1145 eliminates the use of the manual exceptions process for the Medicare Part B therapy caps, making all exceptions automatic going forward. To make this feasible, CMS added to its list of ICD-9 codes that allow for an automatic exception and clarified how to use complexities to justify an automatic exception from the caps. The cap amounts for 2007 are $1,780 on physical and speech-language therapy and $1,780 on occupational therapy.

"It's good [for SNF professionals] because it expands the automatic exceptions process" says Rick Gawenda, PT, director of rehabilitation for Detroit Receiving Hospital and owner of Gawenda Seminars in Ypsilanti, MI. "However, it puts more onus on the provider to use the proper documentation and the KX modifier to describe the patient's condition."

CMS benefits from the switch because it can put more effort into researching the process and reviewing claims, instead of spending money and resources on reviewing each manual exception letter. SNF professionals should take a closer look at how a resident's conditions or complexities actually affect the frequency, amount, and duration of necessary skilled rehab services, according to Gawenda. "Not every person who has high blood pressure needs to exceed the cap," he says.

To view Transmittal 1145 and the updated list of ICD-9 codes and complexities that justify an automatic exception, go to www.hcpro.com/content/65810.cfm.

More documentation changes

Transmittal 63 included CMS' third outpatient rehab documentation update since February 2006. CMS recommended that an evaluation include one of the following assessment tools:

* National Outcomes Measurement System by the American Speech-Language-Hearing Association 

* Patient Inquiry by Focus On Therapeutic Outcomes, Inc.

* Activity Measure--Post Acute Care

* OPTIMAL by Cedaron through the American Physical

* Therapy Association

The transmittal also provides options for therapists who do not perform the above tests.

"It's clear that it becomes more important to do range-of-motion [ROM] muscle testing, balance scores, and other tests and measurements that are more commonly used," Gawenda says. "CMS and other payers want to see progress in terms of ROM or strength testing, progression of gait, balance, and activities of daily living function."

To view Transmittal63, go to www.hcpro.com/content/65811.cfm.