Knee, hip replacements qualify for therapy cap exceptions, CMS says

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The Centers for Medicare & Medicaid Services this week outlined the Medicare Part B therapy caps exceptions process for providers.

The exceptions process allows for two types of exceptions to the outpatient physical, speech and occupational therapy caps, according to CMS: automatic exceptions and manual exceptions. Automatic exceptions cover certain conditions or complexities that are allowed without a written request.

Manual exceptions require submission of a written request by the beneficiary or provider and medical review by the contractor who processes the claims. If contractors do not make a decision within 10 business days, the services are deemed to be medically necessary, according to the Deficit Reduction Act.

Conditions that qualify for an automatic exception to the caps include: knee, hip and shoulder replacements, Parkinson's disease, upper and lower limb amputations, and multiple sclerosis, according to a newly released fact sheet. CMS predicts that the majority of beneficiaries who require services beyond the cap will qualify for automatic exceptions.

Providers have been waiting for information on the exceptions process since therapy caps went into effect Jan. 1 — the date it will be retroactive to. The recently passed Deficit Reduction Act of 2005 directs CMS to create a process to allow exceptions to therapy caps for certain medically necessary services. The caps place a limit of $1,740 on physical and speech therapy and a $1,740 cap on occupational therapy.

The fact sheet is available at