In 2007, Medicare coverage for outpatient physical therapy will have a cap of $1788 allowed charges per year per person. If you are also having Speech Therapy*, those charges will be included in this cap. It is important that you let us know if you have had physical therapy this year at another facility, so we may help calculate the cap accurately.

Depending on the type and amount of physical therapy you need, this cap would be reached in 16 to 26 physical therapy visits. This is well beyond what most of our patients need or receive. Usually, many problems can be treated in 8 to 10 visits or less.

The good news is that many patients who need additional physical therapy beyond the cap will qualify for an automatic exception, meaning the cap amount may be exceeded. Your physical therapist knows all the requirements and our regular documentation standards more than meet CMS (Center for Medicare Services) requirements to justify continued physical therapy. There is no risk to you that you will pay any money out of your pocket when your therapist determines you meet the qualifications for an automatic extension. You do not need to do anything different. With an automatic extension, you will not need to go to a hospital for continued physical therapy on an outpatient basis. If you do not meet the standards for an automatic extension, we can also apply to CMS for a manual extension of benefits. By law, if they do not respond in 2 weeks, the extension is automatically granted.

Medicare has recommended that all providers ask their subscribers specific questions once per year. We will provide this form to you, along with any help you may need in filling it out. This will go to our billing company, Cascade Billing Center, and they will process the forms for you.

There are some diagnoses or conditions that allow patients to receive an automatic exception. Some common ones are listed below:

• Total hip
• Total knee
• Total shoulder
• Diabetes Mellitus
• Neuropathies
• COPD
• Osteoarthritis
• Osteoarthritis, shoulder
• Osteoarthritis, pelvic/thigh
• Osteoarthritis, knee
• Osteoarthritis, shoulder
• Difficulty walking
• Spondylosis with myelopathy
• Cervical disorders
• Spinal Stenosis, lumbar
• Rotator cuff disorders
• Tendon rupture
• Abnormality of gait
• Lack of coordination
• Fracture

Other conditions automatically allow you to receive physical therapy beyond the cap:

• Discharge from hospital or SNF within 30 treatment days
• Generalized musculoskeletal conditions that directly impact the rate of recovery
• Mental or cognitive disorder
• PT and Speech Therapy required concurrently
• Prior episode of outpatient PT during the calendar year for a different condition
• Treatment is needed to return to premorbid living environment
• Treatment needed to reduce assistance with daily activities
• Physical Therapy evaluation

Our therapists are responsible for assessing that you meet the Medicare standards, and documenting appropriately to justify further physical therapy beyond the cap. Be sure to ask your therapist if you have any questions about this!

*REMINDER: Be sure to let us know if you have had Speech Therapy or other outpatient physical therapy.