Exemptions Process Outlined for Implementation of Medicare Caps In a Jan. 27 letter to Congress, the Centers for Medicare and Medicaid Services (CMS) outlined its proposed therapy cap exemptions process, indicating that the policy will retroactively apply to all outpatient therapy services provided since Jan. 1, 2006. CMS was instructed to develop an exemptions process to allow for ... Bottom Line
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Bottom Line  |   February 01, 2006
Exemptions Process Outlined for Implementation of Medicare Caps
Author Notes
  • Ingrida Lusis, is ASHA’s director of health care regulatory advocacy. Contact her by e-mail at ilusis@asha.org.
    Ingrida Lusis, is ASHA’s director of health care regulatory advocacy. Contact her by e-mail at ilusis@asha.org.×
Article Information
Practice Management / Bottom Line
Bottom Line   |   February 01, 2006
Exemptions Process Outlined for Implementation of Medicare Caps
The ASHA Leader, February 2006, Vol. 11, 3-22. doi:10.1044/leader.BML.11032006.3
The ASHA Leader, February 2006, Vol. 11, 3-22. doi:10.1044/leader.BML.11032006.3
In a Jan. 27 letter to Congress, the Centers for Medicare and Medicaid Services (CMS) outlined its proposed therapy cap exemptions process, indicating that the policy will retroactively apply to all outpatient therapy services provided since Jan. 1, 2006.
CMS was instructed to develop an exemptions process to allow for the delivery of medically necessary services above the therapy cap as part of the Deficit Reduction Act (DRA), which passed Congress and was signed into law in early February. The DRA also requires CMS to develop by July 1 code edits to ensure appropriate utilization of therapy services. CMS is expected to issue formal guidance on the process to its contractors in the near future.
In the letter, CMS states that they are exploring a system that would automatically exempt certain medical conditions from the cap, when documentation indicates the need for additional services. Using information from its National Outcomes Measurement System (NOMS), ASHA provided CMS with a list of diagnoses that would most likely exceed the cap and thus qualify for an automatic exemption. ASHA requested CMS to consider automatically exempting any beneficiary who is receiving both physical therapy and speech-language pathology services simultaneously. In addition, ASHA worked with both Congress and CMS to ensure that the process was retroactively applied.
For services that may require more treatment than usual and are not included in the CMS list of diagnoses that are automatically exempt, CMS stated that a beneficiary or provider will have the ability to submit a written request, along with justification to demonstrate medical necessity. The request could be reviewed by the CMS contractor who could approve a number of services beyond the caps when they are justified as medically necessary. Under this scenario, concise documentation will become even more important in justifying continued need for treatment above the therapy cap threshold. Speech-language pathologists should ensure that documentation provides specific information on medical necessity, functional gains, and why continued services are warranted.
SLPs are encouraged to become NOMS-certified providers and to begin submitting outcomes information. NOMS data can assist SLPs in benchmarking their services against others providing services to beneficiaries with similar diagnosis and characteristics and, also to provide critical utilization information that could be used in ASHA’s advocacy efforts. Visit ASHA’s NOMS section for more information.
ASHA will provide detailed information on the exemptions process once it is published by CMS, and will host a telephone seminar in March to provide SLPs with an opportunity to gain in-depth knowledge on the process.
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February 2006
Volume 11, Issue 3