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Update on Medicare Therapy Caps for 2007 Lymphedema

PostPosted: Sun Jan 14, 2007 12:30 am
by patoco
Update on Medicare Therapy Caps for 2007 Lymphedema

The following are abstracts from the recently issued "Outpatient Therapy
Cap Exception Process for 2007". The automatic exception from annual limits for manual lymph drainage has been extended for 2007. Note that primary lymphedema ICD-9-CM diagnostic code 757.0 has lot been listed for automatic exception, and treatment will either have to be justified by medical necessity, or billed under the diagnostic code 457.1 "other lymphedema" other than caused by mastectomy.

MLN Matters Number: MM5478 REVISED
Related Change Request (CR) #: 5478
Related CR Release Date: December 29, 2006
Effective Date: January 1, 2007
Related CR Transmittal #: R1145CP, R181PI,R63BP
Implementation Date: 30 days from issuance


Section 1833(g)(5) of the Social Security Act provided that, for services
rendered during calendar year 2006, FIs, RHHIs, and carriers could, in certain circumstances, grant an exception to the therapy cap when requested by the individual enrolled under the Part B benefit (or by a person acting on behalf of that individual).

On January 1, 2006, Medicare implemented financial limitations on covered therapy services (therapy caps); however, the 2006 Deficit Reduction Act provided for exceptions to this dollar limitation) when the provision of additional therapy services is determined to be medically necessary. This exceptions process has been extended by recent legislation (the Tax Relief and Health Care Act of 2006) for one year (calendar year 2007).

Remember that a therapy cap exception may be made when a beneficiary requires continued skilled therapy, (in other words, therapy beyond the amount payable under the therapy cap) to achieve their prior functional status or maximum expected functional status within a reasonable amount of time. Documentation supporting the medical necessity of those therapy services must be kept on file by the provider.

Additionally, you should note that, in 2006, Exception Processes fell into
two categories, Automatic, and Manual. Beginning January 1, 2007, there is no manual process for exceptions, and all services that require exceptions to caps will be processed using the automatic process.

Key Points

CR 5478, from which this article is taken, provides instructions to
contractors regarding the short term implementation of this legislation.

Details about these instructions follow:

•• Contractors will grant exceptions for any number of medically necessary services if the beneficiary meets the conditions described in the Medicare Claims Processing Manual (100-04), Chapter 5 (Part B Outpatient Rehabilitation and CORF/OPT Services), section 10.2 (The Financial Limitation) for 2007, (displayed in Table 1, below). The following ICD-9 codes describe the most typical conditions (etiology or underlying medical diagnoses) that may result in exceptions (marked X) and complexities that MIGHT cause medically necessary therapy
services to qualify for the automatic process exception (marked *) for each discipline separately. When the cell in the table is marked with a dash (-), the diagnosis code in the corresponding row is not appropriate for services by the discipline in the corresponding column. Therefore, services provided by that discipline for that diagnosis do not qualify for exception to caps. Services may be appropriate when provided by that discipline for another diagnosis appropriate to the discipline, which may or may not be on this table, and that diagnosis should be documented on the claim, if possible, or in the medical record.

Table 1

ICD-9 codes describing diagnoses that may result in excepted conditions
(marked X) and complexities (marked *) that MIGHT cause medically necessary therapy services to qualify for the automatic process exception.

ICD-9 Cluster: 451.0-453.9 and 456.0-459.9

ICD-9 (Cluster) Description: Diseases of Veins and Lymphatics, and Other Diseases of Circulatory System

PT: *
OT: *
SLP: *

•• Medicare contractors will allow automatic process exceptions for diagnoses in the table above or any other diagnosis for which therapy services are appropriate when the beneficiary needs therapy services above the therapy cap (due to the occurrence of any condition or complexity that is appropriately documented).

•• For the therapy HCPCS codes subject to the cap limits in your claims to
be excepted, you must include the KX modifier to indicate that the clinician attests that services are medically necessary and justification is documented in the medical record. In CY 2007, when claims contain a KX modifier, contractors will override edits that indicate that a therapy service has exceeded the financial limitation, and will pay for the service if it is otherwise covered and payable.

•• Contractors will not use the KX modifier as the sole indicator of
services that do exceed caps in 2007, because, there will be services with
appropriately used KX modifiers that do not represent services that exceed the cap.

Robert Weiss, M.S.
Lymphedema Treatment Advocate

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Lymphedema People