Wednesday, February 15, 2006


Background: Section 4541 of the Balanced Budget Act of 1997 (BBA) required the Centers for Medicare & Medicaid Services (CMS) to impose financial limitations or caps on outpatient physical, speech-language and occupational therapy services by all providers, other than hospital outpatient departments. The law required a combined cap for physical therapy and speech-language pathology, and a separate cap for occupational therapy. Due to a series of moratoria enacted subsequently to the BBA, the caps were only in effect in 1999 and for a few months in 2003. With the expiration of the most recent moratorium, the caps were reinstated on January 1, 2006 at $1,740 for each cap. The President signed the Deficit Reduction Act of 2005 (DRA) into law on February 8, 2006. The DRA directs CMS to create a process to allow exceptions to therapy caps for certain medically necessary services provided on or after January 1, 2006. The law mandates that if CMS does not make a decision within 10 days, the services will be deemed to be medically necessary. This fact sheet describes the exceptions process which will be implemented by our claims processing contractors. Until contractors are able to implement the exceptions process, they are required to accept requests for adjustment of claims for services in 2006 that were denied for exceeding the caps.

Exceptions Process
CMS has established an exceptions process that is effective retroactively to January 1, 2006. Providers, whose claims have already been denied because of the caps, should contact their carrier to request that the claim be reopened and reviewed to determine if the beneficiary would have qualified for the exception. In addition, providers who have not yet submitted claims for services on or after January 1, 2006 that qualify for the exception, should submit these claims for payment, and refund to the beneficiary any private payments collected because of the cap. The exceptions process allows for two types of exceptions to caps for medically necessary services:

Automatic Exceptions
Automatic exceptions for certain conditions or complexities are allowed without a written request. A request to the contractor for an exception is not required when services related to these conditions and complexities, which are described below, are appropriately provided and documented. We anticipate that the majority of beneficiaries who require services in excess of the caps will qualify for automatic exceptions.

Manual Exceptions
Manual exceptions require submission of a written request by the beneficiary or provider and medical review by the contractor responsible for processing the claims. If the patient does not have a condition or complexity that allows automatic exception, but is believed to require medically necessary services exceeding the caps–the provider/supplier or beneficiary may fax a letter requesting up to 15 treatment days of service beyond the cap. A treatment day is a day on which one or more services are provided. The request must include certain documentation, including a justification for the request. Contractors will make a decision on the number of treatment days they determine are medically necessary within 10 business days. These requests for cap exceptions should be submitted prior to the date the cap is expected to be surpassed to avoid placing the beneficiary at risk of incurring the costs of treatment if the request is denied.


– just a personal side note. This was helped along by the work of a lot of dedicated patients and loved ones who walked the halls of congress after the first law went into effect. It is also not the first time it has happened. The first time I happened to witness such an amazing act of patients and loved ones in action is in evidence above (the SSDisability codes for CRPS/RSD). I still remember walking the halls of Congress with my dad (Dad O to so many of you), Jim Broatch, Wilson Hulley, Joe, Sandy, and about twelve other patients and their wives/husbands. Two friends who are no longer with us. 

We walked, limped, and some rolled, from one Senators office to the next, pushing for the Codes we needed, explaining what Reflex Sympathetic Dystrophy was (they hadn’t changed the name yet), and why it was so important that Social Security recognize our disease as a disability. The same thing happened with the exemptions legislation. It was amazing seeing such a ragtag group helping to make such amazing things happen. The Senators were so gracious to us, especially Senator Arlen Specter who sat and talked with my dad and I for the longest time. I bring it up to remind patients today that you CAN make a difference. The legislation and other work you are doing today can change lives, today and down the road, in ways you will never imagine. Never give up, even when the day is long, you are exhausted and don’t think you can walk, drag, or roll another foot. My dad passed on a few years ago but I will always have those memories and know they were just some of the many ways he, Jim, Wilson. Joe, and all the other courageous individuals who worked on those campaigns in person and through emails, letters, and calls, reached forward and helped millions of CRPS patients and their families.

  ~ Keith Orsini ~ American RSDHope