Medicare Part B Therapy Cap Exceptions Process

On January 3, 2013, the president signed into law the "American Taxpayer Relief Act of 2012," which extended the therapy cap exceptions process and manual medical review for therapy services in 2013. The following provides speech-language pathologists with relevant information on the exceptions process, manual medical review process, and documentation requirements. Speech-language pathologists may use the automatic exceptions process for any diagnosis and complexity, so long as they have documented justification on why the services for the particular patient exceed the cap. The 2013 therapy cap is $1,900 for speech-language pathology and physical therapy services combined.

Latest Developments

• CMS Clarifies 2013 Manual Medical Review and Critical Access Hospital Therapy Cap Participation (2/25/13)

ASHA Resources

• Overview of the Exceptions Process
• Overview of the Manual Medical Review Process
• Overview of Documentation Guidelines
• National Outcomes Measurement System (NOMS)

CMS Instructions

• Exceptions Process - Medicare Claims Processing Manual, Ch. 5, Sections 10.2 - 10.5 [PDF]
• Documentation - Medicare Benefit Policy Manual, Ch. 15, Section 220.3 [PDF]

Additional Resources

• MedPAC 2006 June Report (Ch. 6) [PDF]
• CSC Pilot & Utilization and Edit Reports
  Optional approaches to the development of alternatives to therapy caps

Questions? Contact reimbursement@asha.org.