CMS considers therapy-cap exception procedures

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Anticipating the passage of the Deficit Reduction Act later this week, the Centers for Medicare & Medicaid Services disclosed to lawmakers how it might implement the therapy-caps exceptions policy.

The policy cannot go into effect until legislation is passed. The House is expected to vote on it as early as Wednesday. Under the policy, a beneficiary will be able to request an exception from the therapy caps for medically necessary treatment. The caps total $1,740 for physical therapy and speech therapy, and $1,740 for occupational therapy. They went into effect this month.

CMS said in a letter to House Energy and Commerce Committee Chairman Joe Barton (R-TX), and two other committee heads, that it is looking into exempting from the caps — without mandating a written request — beneficiaries with certain conditions. Such conditions include a closed head injury or therapy relating to a broken arm in the same year that the patient receive a hip injury, the letter said. These exemptions would occur whenever there is a documented need for the services.

For other cases, providers or beneficiaries would submit a written request for a therapy cap exception, along with a medical necessity justification, CMS said. Contractors would then review the requests and if they deem there is medical necessity, approve a number of services beyond the caps.

CMS said it would allow adjustment between the caps' effective date of Jan. 1 and implementation of the exception process. House Ways and Means Committee Chairman William M. Thomas (R-CA) and Senate Finance Committee Chairman Charles E. Grassley (R-IA) also received the letter.