The information below was sent from Trailblazer Health. Although some
of this information was posted on this listserv in February, it is of
note that Trailblazer Health highlights the difference between the
diagnosis codes in the LCD and the diagnoses that would constitute an
exception process of the medicare cap. It is also noteworthy that a
very high utilization rate of the KX modifier has been identified.
CMS has been very clear that this modifier IS NOT to be used with
every case. Clinics that show this type of pattern run a high risk of
detailed audits.

Be assured that the APTA is active in communicating with Trailblazer
Health regarding the crosswalk and suggesting necessary
modifications.

Please send any questions to my attention at
AngelaSBrooks@....

Angela S. Brooks, PT
VPTA Payer Relations Specialist


______________________________________________________________________

From the Desk of the Medical Director


Notice: Outpatient Physical Medicine and Rehabilitation Services LCD




In 1997, Congress imposed a cap on the amount of therapy services
(physical and occupational therapy and speech-language pathology
services) for which Medicare may pay for an individual patient in a
given year. Each year since then, Congress has either suspended the
cap or provided some other means to bypass the cap. The cap was based
on an estimate of the amount of therapy services the average Medicare
beneficiary might need to rehabilitate from a single injury or
illness. For dates of service in Calendar Year (CY) 2006, Change
Request (CR) 4364 provided instructions for both an automatic and a
manual exception process that allowed for payment of additional
reasonable and necessary therapy services. In conjunction with the
initiation of this exception process in 2006, Trailblazer temporarily
suspended its procedure to diagnosis editing related to the Y-18
Outpatient Physical Medicine and Rehabilitation Services Local
Coverage Determination (LCD).


For dates of service in CY 2007, Congress has instructed CMS to
continue with an exception process. This was communicated to Medicare
contractors in CR 5478 (see MLN Matters article MM5478 ). The
automatic exception process, through the use of the KX modifier will
be continued; the manual exception process will not. This CR contains
the business requirement "Contractors shall continue to enforce LCDs,
since the presence of a KX does not supersede a Local Coverage
Determination (LCD) in CY 2007." In light of this requirement,
TrailBlazer will resume procedure to diagnosis editing that was
suspended last year. This editing will go into effect for dates of
service on or after March 16, 2007.



As in the original CR 4364, CR 5478 refers to a list of diagnosis
codes that describe the conditions (etiology or underlying medical
conditions) that may result in excepted conditions and complexities
that might cause medically necessary therapy services to qualify for
the automatic process exception. Acceptable use of each diagnosis
code is identified by each of the three therapy disciplines (physical
and occupational therapy and speech-language pathology services). The
LCD also has a list of diagnosis codes. The two lists have different
functions. The list of diagnoses in the LCD are those conditions for
which that specific service may be "reasonable and necessary" for the
care of the patient. The list in the exception process included in CR
5478 indicates those conditions for which additional therapy beyond
the limitations of the CAP might be necessary.



Preliminary analysis of data regarding the effect of the "exception
process" in 2006 reveals that a number of providers in both Part A
and B TrailBlazer jurisdictions have included the bypass modifier
(KX) on claims for 100 percent of their patients. TrailBlazer will
conduct additional analysis and record reviews as a part of its
Program Integrity responsibilities. Providers may reference
TrailBlazer LCDs on the TrailBlazer Coverage Policies Web page.