In February 2006, the President signed the Deficit Reduction Act of 2005 (DRA) into law. The Centers for Medicare & Medicaid Services (CMS) was directed to create a process to allow for certain exceptions to the financial therapy cap limitation. CMS released Change Request (CR) 4364 in February 2006 to instruct Medicare contractors and providers on how to process requests for medically necessary therapy services that were beyond the financial limitation. Exception process instructions and manual information may be found in CMS CR 4364, Pub. 100-02, Transmittal 47, dated Feb. 16, 2006; Pub. 100-08, Transmittal 140, dated Feb. 16, 2006; and Pub. 100-04, Transmittal 855, dated Feb. 16, 2006, on the CMS Web site at: http://www.cms.hhs.gov/transmittals

The annual limit on the allowed amount for outpatient physical therapy and speech-language pathology combined is $1,740. The annual limit on the allowed amount for occupational therapy is also $1,740.

For each request, the following documentation is required.

• Provider name
• Medicare provider number
• Beneficiary name
• Health Insurance Claim (HIC) number
• Contact name and telephone number
• Indicate if this is for a manual exception request or retroactive reopening

Required supporting documentation:

• Number of treatment days requested
• Number of retrospective days requested
• Number of prospective days requested
• Evaluation and certified Plan of Care
• Certification
• Progress reports
• Treatment encounter notes
• Justification documentation

TrailBlazer Health Enterprises, LLC will be processing your requests for additional therapy in the following manner:

• Submit requests for reopening and manual exception to: fax (469) 372-7739.
• Requests for reopening should only be submitted for medically necessary services that have been denied for exceeding the cap and do not meet the automatic exception.
• Requests for manual exceptions should be submitted when the patient is nearing the cap limit and does not meet the requirements for an automated exception but the provider believes it is medically necessary for further therapy services. Fax these requests with all of the documentation outlined in Transmittal 47 Pub. 100-02. www.cms.hhs.gov/transmittals/downloads/R47BP.pdf
• If the cap has not been exceeded, a request for reopening is inappropriate. If services have been denied for another reason, follow the redetermination process.
• If the cap will be exceeded and the services meet the automatic exception, submit the services with the -KX modifier and do not request manual exception.

Claims that meet the automatic exception but were denied for exceeding the cap should be resubmitted with the -KX modifier. Requests for reopening in this case simply delay the process and are not necessary. Documentation supporting medical necessity must be maintained in the provider file and not submitted with the claim.