CGS Issues Instructions on Outpatient Therapy Cap

The Therapy Cap does not apply to Traditional PPS Home Health Part A and Part B Episodes.  The Therapy Cap applies to Home Health Therapy Episodes that are not part of the home health plan.  These are the Physical Therapy, Occupational Therapy and Speech Pathology visits that are billed as Outpatient Part B and are paid based on the fee schedule.  They also have a 20 percent copayment.

For the dates of services January 1, 2013 through December 31, 2013, all outpatient therapy claims submitted above the $3,700 threshold will be subject to prepayment medical review.  CGS will request the following documentation:

1.     Justification

2.     Evaluation or reevaluation(s) for Plan(s) of Care

3.     Certification of the Plan of Care

4.     Objective and measurable goals and any other documentation requirements of the Local Coverage Determination

5.     Progress reports

6.     Treatment notes

7.     Certification or Recertification for therapy services

8.     Any orders, if applicable, for additional therapy services

9.     Any additional information requested by CGS

For more information please utilize the following link.

http://www.cgsmedicare.com/hhh/pubs/news/2013/0313/cope21556.html