Therapy and rehabilitation services FAQs



Coverage/Documentation requirements
If a physical therapy evaluation is signed by the physician, may it be used as the certification?
The criteria for “timely certification” of the initial plan of therapy have been met when the physician/non-physician practitioner’s certification of the plan has been documented (by signature or verbal order) and has been dated within the 30 days following the first day of treatment (including evaluation). Certification requirements have been met when the physician has certified the plan of care. If the signed order includes a plan of care, no further certification of the plan is required.

Does Medicare require a prescription/order for therapy and the plan of care to be signed by the physician?

An order for therapy services, if it is documented in the medical record, provides evidence of both the need for care and that the patient is under the care of a physician. However, the plan of care differs in that the plan must be certified. For example, if during the course of treatment -- under a certified plan of care -- a physician sends an order for continued treatment for two more weeks, then the order is acceptable as a certification to continue treatment for that time period under that plan of care, which is considered to be separate.

Are the documentation elements for the discharge summary the same as for the progress report?

The progress report provides justification for the medical necessity of treatment being provided. At a minimum, the progress report period is every 10 treatment days, or at least once during each certification interval or 30 calendar days, whichever is less. The discharge summary is required for each episode of outpatient treatment and must cover the reporting period from the last progress report to the date of discharge. The progress report includes an assessment of improvement of the patient’s condition toward each goal and their extent of progress; if there hasn’t been any improvement that needs to be noted as well. The progress report should also include: any plans for continuing treatment; reference to additional evaluation results; treatment plan revisions if applicable; changes to long or short term goals; or discharge. The discharge note can be the progress report written by the clinician.

KX modifier/automatic exception

What are the financial limits for therapy caps?
Limits for therapy caps may vary from year to year. For 2013, the limit for physical therapy and speech-language pathology services combined was $1900.00, and the 2013 limit for separate occupational therapy services was $1900.00.
In 2014, the limit for physical therapy and speech-language pathology services combined was increased to $1,920.00, and the 2014 limit for separate occupational therapy services was also changed to $1,920.00.

What is an “automatic exception”?

An “automatic exception” may be made when a beneficiary’s condition has been justified by documentation indicating that he or she requires continued skilled therapy (i.e., therapy beyond the amount payable under the therapy cap) to achieve his or her prior functional status or maximum expected functional status within a reasonable amount of time.
Clinicians may utilize the automatic process for exception for any diagnosis for which they can justify services exceeding the cap.

May I append the KX modifier to all of my therapy claims?
No. The modifier only applies to medically necessary services that exceed the limitation, not before.

Is the KX modifier to be used for services exceeding the cap even if the patient is not diabetic?
When exceptions are in effect and the beneficiary qualifies for a therapy cap exception, the provider must add a KX modifier to the therapy Healthcare Common Procedure Coding System (HCPCS) code subject to the cap limits. In addition to the KX modifier, the GN (Services delivered under an outpatient speech-language Pathology), GO (Services delivered under an outpatient occupational therapy plan of care), and GP (Services delivered under an outpatient physical therapy plan of care) modifiers are to continue to be used. By appending the KX modifier, the provider is attesting that the services billed:

• Are reasonable and necessary services that require the skills of a therapist
• Are justified by appropriate documentation in the medical record
• Qualify for an exception using the automatic process exception
Whether or not a patient is diagnosed with diabetes does not have a direct correlation for appending the KX modifier to a claim.

Will usage of the KX modifier continue to be permitted by Medicare?
On April 1, 2014, the President signed the “Protecting Access to Medicare Act of 2014,” which extends the exceptions process for outpatient therapy caps through December 31, 2014.

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