Medicare still allows exceptions to rehab caps

Washington -- Medicare's spending caps on physical, speech and occupational therapy will continue this year, but so will the process doctors can use to lift the limits when needed.

Under program rules, the government will stop paying once a beneficiary racks up $1,780 worth of combined physical and speech therapy this year. A separate $1,780 cap applies to occupational therapy. Both cap levels have increased $40 from 2006 to account for inflation.

But as part of a massive health, tax and trade bill that Congress passed and President Bush signed into law in December 2006, lawmakers approved a one-year extension of the therapy cap exceptions process that was in place for part of 2006.

Under that system, a physician ordering therapy can help a patient receive Medicare coverage beyond the limit if the government deems the additional care medically necessary.

The move comes as good news to both physicians and nonphysicians who practice physical medicine and rehabilitation.

They had argued that the expiration of the exceptions process at the end of 2006 would have put seriously disabled patients who hit the caps at risk for losing access to vital specialized care.

"Data show that patients with stroke, hip fracture, Parkinson's disease and other conditions that require extensive rehabilitation are most likely to be affected by the arbitrary Medicare therapy caps," said R. Scott Ward, PhD, president of the American Physical Therapy Assn. "While legislation repealing the therapy caps is the best long-term policy solution, this legislation would take an important step forward to protect Medicare beneficiaries from the impact of a 'hard' therapy cap."

A physician can obtain automatic exceptions for patients who fit under one of more than 100 diagnosis codes corresponding to a serious condition or complexity, such as a knee joint replacement or diabetes mellitus. A doctor whose patients don't fit in one of these categories still can help them out by applying for "manual" exceptions from the appropriate Medicare carriers and submitting documentation demonstrating that therapy above the cap is medically necessary.

Patients also are exempt from the caps if they receive their care from a hospital outpatient department instead of a physician's office or stand-alone rehab center.

When the Centers for Medicare & Medicaid Services first unveiled the exceptions process in February 2006, CMS officials said relatively few patients would hit the cap and not qualify for an automatic exception. But physicians complained that for the patients who didn't immediately qualify, doctors were being asked to go through a burdensome bureaucratic process just to demonstrate that the care was medically necessary -- a standard that they said is already built into Medicare.

Physicians didn't have as much experience with the exceptions process as they could have in 2006 because it was only in place for part of the year, said Robert B. Goldberg, DO, a physiatrist from New York.

"This year will really be the test, because it will be in place from the get-go," he said. Physicians and patients need to keep track of how much Medicare therapy spending they have incurred since the start of the year to know when they will reach the cap levels and to plan exceptions applications accordingly.

The American Physical Therapy Assn. and the American Academy of Physical Medicine and Rehabilitation will continue pushing Congress to eliminate the caps entirely. They say that the confusion and burden associated with the limits could cause some patients to miss out on needed care even if they are eligible for it.

Rep. Phil English (R, Pa.), who led the charge to renew the exceptions process in December 2006, said that he would continue pushing for a full repeal.

"Whether a person receives speech, occupational or physical therapy, it should be a decision made between a doctor and a patient, not by accountants monitoring a set limit," English said.