1-03-07
CMS Eliminates Manual Cap Exception Process, Changes Documentation Requirements
AOTA is aware of the need for materials to assist occupational therapists to comply with the new CMS requirements described below. AOTA is working as quickly as possible to develop these guidance materials. They will be posted on the AOTA Web site as soon as they are available.
On December 29, 2006, the Centers for Medicare & Medicaid Services (CMS) issued two new transmittals, changing transmittals that contain important Medicare outpatient therapy policy changes. Both transmittals were published on December 29; became effective on January 1, 2007; and are to be implemented on or before January 29.
Transmittal 1145 contains changes to the cap exception process. Most notably, it eliminates the manual process for obtaining an exception to the cap. All services that require exceptions to caps shall be processed using the automatic process and should be made in the form of a KX modifier added to claim lines.
- The KX modifier is used to indicate that the clinician attests that services are medically necessary and justification is documented in the medical record. Transmittal 1145 also contains an updated list of conditions or complexities represented by ICD-9 codes that may be automatically excepted from the cap. Although clinicians may use the automatic exception process for beneficiaries who do not have a condition or complexity on the list, their documentation must then provide sufficient justification for excepting the patient from the cap.
Transmittal 63 requires practitioners to include in their documentation of evaluations either the results of a specified performance measure tool or an explanation of certain factors. Specifically, the practitioner may report the results of one of the following measurement tools: the National Outcomes Measurement System (NOMS) by the American Speech-Language-Hearing Association; the Patient Inquiry™ by Focus on Therapeutic Outcomes, Inc. (FOTO); the Activity Measure for Post-Acute Care (AM-PAC); or the Outpatient Physical Therapy Improvement in Movement Assessment Log (OPTIMAL) by Cedaron, through the American Physical Therapy Association.
If the practitioner chooses to not record the results of one of those four instruments, then the documentation must contain information
- supporting illness severity or complexity,
- supporting medical care prior to the current episode,
- required to indicate beneficiary health related to quality of life,
- required to indicate beneficiary social support, and
- required to indicate objective measurable beneficiary physical functioning.
Transmittal 63 also contains additional policy clarifications and reiterates CMS' policies concerning billing for group outpatient therapy and for the services of therapy students in outpatient settings.
AOTA will be working with CMS to obtain clarification on aspects of Transmittals 1145 and 63. The development of an outcomes data measurement system focused on occupational therapy is an AOTA priority. In the interim, until such system can be implemented, AOTA is working internally and with CMS to develop mechanisms for occupational therapists to meet CMS's new documentation requirements.