Overview of the Medicare Therapy Cap Exceptions Process
Speech-Language Pathology Services
The exceptions process allows beneficiaries to access medically necessary Medicare Part B outpatient therapy services above the therapy cap. The following provides speech-language pathologists with a general overview of the Centers for Medicare & Medicaid Services (CMS) therapy cap exceptions process. It is imperative that speech-language pathologists familiarize themselves with this process as CMS has placed a greater emphasis on a clinician's professional judgment as well as increased documentation requirements to ensure medically necessary services are being provided.
Automatic Exceptions Process—Emphasis on Clinical Judgment & Medical Necessity
The automatic process and the use of the KX modifier is the only way a clinician can request an exception from the therapy cap. 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.
In addition, CMS will apply the exceptions process to therapy evaluation procedures after the therapy cap is reached when evaluation is necessary (e.g., to determine if the current status of the beneficiary requires therapy services). Speech-language pathology related codes include CPT 92506, 92507, 92520, 92597, 92607, 92608, 92610, 92611, 92612, 92614, 92616, 96105, 96125, and 97532. To obtain a complete list of evaluation procedures that are recognized for coverage above the cap, go to CMS' Annual Therapy Update webpage.
Claims submitted when expenditures for combined speech-language pathology and physical therapy reach a $3,700 threshold will be stopped and subject to manual medical review. To avoid a long review process, providers can request pre-approval for therapy services over the threshold for up to 20 treatment days. See Medicare Part B Manual Medical Review Process for Therapy Claims for more information.
Use of the KX modifier
When the beneficiary qualifies for a therapy cap exception, the KX modifier is required with the CPT/HCPCS code to be used on the claim form. The KX modifier can be included with claims prior to reaching the cap. The patient’s current accrued claims amount cannot be known for certain because other provider claims may have been submitted but not yet processed by the Medicare Administrative Contractor.
For speech-language pathology services, when the cap is exceeded by at least one line on the claim, use the KX modifier on all of the lines on that claim that refer to physical therapy and speech-language pathology services, regardless of whether the other services exceed the cap.
By appending the KX modifier, the SLP is attesting that the services billed:
- are reasonable and necessary services that require the skills of the SLP;
- are justified by appropriate documentation;
- qualify for an exception.
The use of the GN modifier to identify speech-language pathology services is still required, in addition to the KX modifier. Providers may report the modifiers on claims in any order. (For example: GN, KX 92507)
Documentation Is A Critical Factor in Automatic Process
Documentation is key to ensuring compliance with the exceptions process. The speech-language pathologist's use of the KX modifier is an attestation to CMS that services are medically necessary and justification of the need for services above the cap is documented in the medical record. CMS continues to warn clinicians that the use of the automatic process for exception does not preclude a contractor from conducting other forms of medical review. Atypical use of the automatic exception process may invite contractor scrutiny. If CMS finds that documentation does not support the provision of services above the cap, the SLP may be subject to sanctions under the False Claims Act. CMS has stated that the Medicare contractor has the authority to make the final determination on whether or not to pay the claims.
Due to the increased reliance on the clinician's professional judgment, the need to appropriately document services is imperative. Documentation must show that skilled therapy services are medically necessary and that there is an expectation that the patient's condition will improve significantly in a reasonable and generally predictable period of time. Additional information on CMS documentation requirements can be found at ASHA's website or in Chapter 15, Section 220.2 of the Medicare Benefit Policy Manual [PDF]. In documenting patient outcomes and improvement, CMS has suggested the use of ASHA's National Outcomes Measurement System (NOMS). Additional information can be found on the NOMS section of the ASHA website.
In justifying exceptions from therapy caps, speech-language pathologists should document the medical conditions and/or complications associated with the patient. When a patient's condition is the reason for the exception, that condition must be related to the therapy goals and must either be the condition that is being treated or a complexity that directly and significantly impacts the rate of recovery of the condition being treated such that it is appropriate to exceed the caps.
Contact firstname.lastname@example.org for questions.