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.
- When the $1,740 cap limit has been reached and the patient meets one of the automatic
exceptions, you will need to file or re-file the claim with the GN, GO, GP and KX modifier.
You do not need to submit a re-determination or a manual request.
Automatic exceptions are therapy cap exceptions allowed for certain diagnoses that are
identified and listed in the Claims Processing Manual, Pub. 100-04, Chapter 5, (CR 4364,
Transmittal 855) or, the beneficiary meets a level of complexity that can justify an exception
for a condition that requires skilled therapy. No specific documentation is submitted to the
contractor if the patient qualifies for automatic exception to the cap.
The -KX modifier is used as an attestation of medical necessity for the continued service.
(See Section 10.2 C.3, “ICD-9-CM Codes That Qualify for the Automatic Therapy Cap Exception
Process Based Upon Clinical Condition or Complexity”) at:
www.cms.hhs.gov/transmittals/downloads/R855CP.pdf
Note: The services rendered must be medically necessary and documented in the
beneficiary’s medical record.
- If the patient does not meet the automatic exception, a request can be made for a manual
exception.
Manual exceptions are therapy cap exceptions that require submission of a written request
for medical review of documentation and exception to the cap for patients that do not meet
the criteria for automatic exception. When a provider believes the beneficiary needs more
therapy visits than those payable under the cap, a written request can be submitted by the
provider/supplier or beneficiary. Supporting documentation must be submitted along with a
request for a specific number of additional therapy visits, not to exceed 15 per discipline.
Requests for exception should be submitted before the cap, or each extension, is exceeded to
avoid placing the beneficiary at risk for the cost of any denied services in excess of the cap.
Note: The form and information regarding manual exceptions and the process for requesting
and documenting exceptions can be located at:
http://www.trailblazerhealth.com/partb/downloads/TherapyCapExceptionRequestForm.pdf
