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Therapy Over the Cap

September 8, 2015 1 Comment

It’s that time of the year when therapy providers are carefully reviewing the potential for therapy over the cap Medicare Therapy Capfor each of their Medicare patients.  Beneficiaries may need to exceed the therapy cap for several reasons:

  1.  A single complicated episode of care.
  2. Multiple related episodes of care.
  3. Multiple unrelated episodes.
  4. Using both physical therapy and speech therapy in the same year, as they come under the same therapy cap.

Documenting Effectively for Therapy Over the Cap

Any diagnosis can quality for therapy over the cap, the devil is in the details of the documentation, and it starts with the evaluation.  During the initial evaluation the clinician should note complexities and comorbidities present, and how they will affect the plan of care and the progress that the patient will make.   Therapists are often good at identifying the complexities and comorbidities (especially in the presence of EMR prompts to do so), but often fail to link them to their predicted impact on the course of therapy.  Documentation should be clear, and identify based upon the evaluation how to setup the need for a therapy program that may require more visits, a different approach to therapy, or more frequent reevaluations or even a skilled maintenance program.  Objective tests and measures as well as other clinical findings from the therapy examination and evaluation along with the expert insight of the clinician determine the medical necessity for skilled therapy services.

CMS provides guidance on therapy over the cap:

In making a decision about whether to utilize the exception, clinicians shall consider, for example, whether services are appropriate to:  The patient’s condition, including the diagnosis, complexities, and severity; The services provided, including their type, frequency, and duration; and The interaction of current active conditions and complexities that directly and significantly influence the treatment such that it causes services to exceed caps.

During the next 10 visits, on the way to the progress report keep track of treatment sessions and ask yourself:

  • Am I continually reassessing the patient?
  • Am I updating objective tests and measures?
  • Am I progressing the patient in the treatment session and in the home exercise program?
  • Am I noting the patient’s response to therapy, and their active participation in their HEP?

At the 10th visit your progress report should demonstrate the medical necessity for continued care, and it not, therapy should be wrapped up and the patient discharged.  If this first progress report doesn’t demonstrate  medical necessity for continued care, it likely won’t by the second progress report – the point when the patient is in all probability over the therapy cap.

As the therapy cap approaches for your patients consider a contemporaneous peer clinical review to ensure that all the correct clinical information to support the medical necessity for continued skilled therapy or skilled maintenance therapy is documented: in the evaluation and in the important first progress report.

Do you have patients approaching the cap?  Do you concurrently review the medical necessity for continued care at the first progress report before the patient reaches the therapy cap?

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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  1. Therapy Over the Cap | HealthBACON | September 9, 2015

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