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In a letter to Congress, the Centers for Medicare and Medicaid Services (CMS) outlined its proposed exemptions process (PDF format), indicating that the policy will retroactively apply to all outpatient therapy services provided since January 1, 2006.
CMS states that they are exploring a system that would automatically exempt certain medical conditions from the cap, whenever there is documentation for need of additional services. In the case where medical conditions or circumstances, which typically do not require extensive services in a typical patient, may require more services than usual, a beneficiary or provider could 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.
CMS has also stated that they will retroactively adjust claims denied due to the application of the therapy caps for services provided between January 1 and the implementation of the exceptions process.
CMS has not issued formal instructions to its contactors. ASHA will provide more detailed information as it becomes available. For more information, visit the Therapy Cap Advocacy Center on our site, or contact Ingrida Lusis, ASHA's Director of Health Care Regulatory Advocacy, via e-mail at ilusis@asha.org or by phone at 800-498-2071, ext. 4482.
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