Therapy CAP Exception Preapproval Process
The Weston Group
Therapy CAP Exception Preapproval Process
The following outlines The Weston Group’s implementation of the Therapy CAP Exception Preapproval Process. The process addresses patients currently on caseload and patients identified for services after September 15, 2012.
Existing Caseload
1. The Billing Department will develop a spreadsheet of all patients currently on caseload, by facility.
2. The Billing Department will provide the cumulative benefit total dollar amount for each patient (PT /SLP and OT services) on the spreadsheet through July 31st, 2012.
3. The spreadsheet will be provided to the RDOs and VPs initially and to each facility by the Billing Department.
4. Therapists at each facility will retroactively go back to August 1, 2012 paper Billing Logs through the current treatment date and:
a. count the number of treatment units delivered (Count OT units separately from the combined PT and Speech Units) to each patient identified on the spreadsheet; evaluations should be counted as 4 units
b. multiply the total number of units by 28
c. add that sum to the cumulative benefit total dollar amount provided on the spreadsheet
d. record that sum on the Medicare Part B CAP Tracking Form and initiate tracking of units of service delivered daily.
5. Patients on caseload with a total dollar expenditure of $2500 or more for PT and ST, or $2500 for OT must be submitted to the Billing Department for an Advance Exception (AE) request.
Procedure:
Meet with the patient and/or POA, as appropriate, to explain and provide:
a. The Weston Group’s beneficiary letter
b. The ABN (Advance Beneficiary Notice) and obtain a signature, if applicable
c. Plan for either the continuation of services or Hold services if patient does not want to continue services during the 10 day Medicare review:
1. complete the appropriate MAC (Medicare Authorized Contractor) ‘Therapy CAP Exception Preapproval Request’ Cover Sheet
2. Submit the Cover Sheet along with all the documentation required by the MAC including the ABN if signed, to the Billing Department by efax.
3. The Billing Department will notify the therapist when the Advance Exception Request has been approved OR service may be restarted after 10 business days.
Attachments:
The Weston Group’s Beneficiary Letter and Handout
Medicare Part B CAP Tracking Form
Advance Beneficiary Notice
Therapy CAP Exception Preapproval Request Cover Sheet
Required Documentation
New Patients – Effective September 15, 2012
1. An Insurance Verification will be submitted on all potential new patients
2. The Billing Department will verify the patient’s insurance and provide the total beneficiary dollar amount for the calendar year.
3. Record the beneficiary dollar amount of the calendar year on the Medicare Part B CAP Tracking Form and initiate tracking of units of service delivered daily.
4. Any patient with a total of $2500 or more for PT and ST, or $2500 for OT will require an Advance Exception to be submitted.
a. Obtain Physician Order and Plan of Care certification
b. Complete a 700 Form addressing all of the required preapproval information. It will be very important to provide Medical Necessity for service and skilled interventions requiring a licensed professional.
c. Complete a Billing Log for day 1 with the evaluation and HCPCS included.
d. Submit the appropriate MAC Cover Sheet with the Physician Order and Plan of Care certification, 700 Form (unsigned by the physician) and the Billing Log to the Billing Department efax and call the Billing Department to verify that the Advance Exception has been received specifying from what facility and for what patient.
5. The Billing Department will notify the facility by fax when the Advance Exception Request has been approved OR services may be started after 10 business days.
Attachments:
Insurance Verification
Physician Order and Plan of Care certification
The Weston Group’s Beneficiary Letter
Medicare Part B CAP Tracking Form
Advance Beneficiary Notice
Therapy CAP Exception Preapproval Request Cover Sheet
Ongoing Patients Preapproved for 20 Treatment Days:
1. Once treatment has begun for the next preapproved 20 treatment days, note the date services were initiated on the Billing Log.
2. On day 10 of treatment, initiate Advance Exception process for preapproval of the subsequent 20 treatment days:
Procedure:
Meet with the patient and/or POA, as appropriate, to explain and provide:
a. The ABN (Advance Beneficiary Notice) and obtain a signature
b. Plan for either the continuation of services or Hold services if patient does not want to continue services during the 10 days Medicare review:
1. complete the appropriate MAC (Medicare Authorized Contractor) ‘Therapy CAP Exception Preapproval Request’ Cover Sheet
2. Submit the Cover Sheet along with all the documentation required by the MAC including the ABN if signed, to the Billing Department by efax.
3. The Billing Department will notify the therapist when the Advance Exception Request has been approved OR service may be restarted after 10 business days.
Attachments:
Advance Beneficiary Notice
Therapy CAP Exception Preapproval Request Cover Sheet
Required Documentation