• Blog Post

Alzheimer’s and Related Dementia Services Under Medicare B Cap Exceptions

As of January 1, 2006, the moratorium on a Medicare B financial limitation (Cap) expired. For the calendar year of 2006, the new annual limit on the allowed amount for outpatient physical therapy and speech-language pathology combined is $1,740 and a separate $1,740 for occupational therapy. The Deficit Reduction Act was signed on February 8, 2006. Included in this Act was a direction to CMS to develop a process to allow for exceptions to the caps in cases where continued therapy services are medically necessary.


Analysis of previous Medicare B therapy claims indicated that 17% of OT, 14% of PT, and 11% of SLP beneficiaries would require services beyond an established cap. So this new 'exceptions' process is related to ICD-9 codes (not dollars), most of which we know as medical diagnoses and a few that we use as treatment diagnoses. The list of diagnoses from CMS was developed from history of claims and multiple other processes. The ICD-9 codes that may qualify to go over the cap are indicated as "conditions" and "complexities."


''Conditions'' are ICD-9 codes (both medical and treatment) that may automatically (meaning = without prior documentation submission) indicate a medical necessity to extend therapy involvement beyond the cap. ''Complexities" are ICD-9 codes that indicate with another condition, therapy involvement may be required beyond the cap. A new line item modifier is required to indicate these exception services = KX. The use of this KX modifier on each line item billing indicates that therapy documentation exists to prove the medical necessity of providing annual service beyond the Medicare B financial limitation.


Medical necessity is defined by CMS in the Medicare Benefit Policy Manual under "Reasonable and Necessary" (R&N). Contractors LCDs (Local Coverage Determinations) do take precedence. You must know what Fiscal Intermediary (FI) or Carrier that you bill through. "Reasonable and necessary" are defined as "services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist. . . . There must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time, or the services must be necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease state. In the case of a progressive degenerative disease, service may be intermittently necessary to determine the need for assistive equipment and/or establish a program to maximize function."


On the list of ICD-9 codes provided by CMS as an "automatic" exception to go beyond the cap is the condition of Alzheimer's disease (331.0).


On the list of ICD-9 codes provided by CMS that are provided as "complexities" are the Dementias (290.0 – 290.4).


Neither of these "automatic" or "complex" codes can proceed with service beyond the cap without documentation supporting medical necessity.


Therapy for Alzheimer's Patients (ICD-9 code 331.0) Automatic List
If Alzheimer's disease is a primary medical diagnosis, the "condition" may indicate a need for therapy service to extend beyond the cap. Alzheimer's is listed as an "automatic" exception. Inherent in this diagnosis is a progressive disease. Direct therapy may be needed to "restore" prior or optimal levels of function in life. Direct therapy may be needed to establish a "maintenance program" which evaluates levels, trains caregivers, and periodically evaluates the program. This diagnosis alone does not guarantee that service beyond the cap is automatic. Specific treatment diagnosis and additional medical diagnosis define intervention approaches. Example: A person with Alzheimer's (331.0) may be experiencing difficulty with eating (783.3). While 783.3 is not on the list of automatic exceptions, the "condition" of Alzheimer's is and thus supports any other medical necessity codes.


Therapy for Dementia Patients (ICD- 9 codes 290.0-290.4) Complexities
If Dementia is a primary diagnosis, another "condition" needs to be listed. This may be another medical diagnosis or treatment diagnosis. These codes alone do not upon billing support services go beyond the established caps. In most cases, there are other supporting diagnosis, either medical or treatment.


Two ICD-9 codes listed as "complexities" would require additional coding to support intervention. Example: Difficulty in walking (719.7) is also a "complexity." An additional ICD-9 code or replacement code could be identified, such as "Abnormality of Gait" or "Lack of Coordination." The additional codes supporting treatment do not have to be on the exceptions list but should be specific as possible. Two treatment diagnoses may often be necessary and included on the claim.


Commonly Used ICD-9s Not on the Exception List
780.99, Decreased Functional Activity and 799.3 Debility Unspecified are not on the exception list. These are codes that have frequently been used for dressing/grooming tasks and even lack of participation in activities. Therapists should indicate a more refined reason for the lack of these abilities. Joint instability, coordination, muscle wasting disuse atrophy, shortness of breath, abnormal or imbalance of posture may be other indicators. Decreased Functional Activity may be used as a second treatment indicator. The final decision for accepting a claim always lies with the Medicare contractor. Clinical analysis and supporting documentation are the keys to reimbursement.


Treatment and Medical Diagnosis Need to Fit
The medical and treatment diagnoses submitted need to make sense and reveal why a person is receiving therapy services, especially services that exceed the financial limitation. Even though a medical condition is on the exceptions list, the reason a discipline is intervening needs to be clear.


For instance, Hip Replacement is an automatic exception. Dysphagia is an automatic exception. The two together as the only codes do not make sense. There needs to be another supporting reason for the dysphagia. Dementias are listed as complexities. "Memory Loss" is listed as an automatic exception. Dementia by definition has memory loss as a component, thus the two alone do not support intervention. Another "reason" would need to be added. This may be an example of adding 780.99, decreased functional ability, to treatment diagnosis when no others apply to dressing/grooming.


Reasoning: The dressing/grooming abilities are impacted by a memory loss and that memory loss is more complex with the overall dementia. Your documentation must support this complex situation and the need for skilled intervention.


Our hearts hurt when we see someone lost in their environment and unable to participate in activities. Possibly through your intervention you have instituted procedural memory, adaptations, and assisted with dressing/grooming/eating in a previous course of treatment. Identifying the need for involvement in activities alone is difficult to justify skilled intervention, especially if the Medicare B financial limitation has already been met.


When first evaluating a person with Alzheimer's or related dementias, make sure that the entire life of the person is addressed. As you prioritize goals and meet them, add (or begin with) participation in activities as the important component of a sense of well-being. Lack of meaningful involvement in the day may be the factor that causes inability with dressing/grooming. So the ultimate goal may be participation in self-cares that is being impacted by a sense of "ill-being." If dressing/grooming/eating is addressed first, then generalize those adaptations and training to the rest of the day. Do it all in one course of treatment. Going beyond the Medicare cap should have already been established by your choice of ICD-9 codes.


If you are a therapist who follows a previous intervention in which activities were not addressed and the cap has been reached, pull out the stops on all your clinical reasoning skills! Your choice of ICD-9 treatment diagnosis is very important. Try not to duplicate previous treatment diagnosis. If you have supporting codes on the exceptions list, you may proceed. Just be aware that your documentation may be requested. You may have to also document significant change. If a person is not participating in activities, that isolation, numbness, wandering, staring, behavioral display will show elsewhere. You may need to develop a new Maintenance Program and train caregivers & activity staff again.


Activities for a person with Alzheimer's or related dementias are not "leisure" activity. It is occupation! 


Other Factors
In the case of a course of treatment extending beyond the cap, the KX modifier on each line item of billing attests to the fact that the therapist has the supporting documentation to justify this extension of service. The therapist needs to apply the KX modifier, not the billing office. Supporting ICD-9 codes and documentation needs to be in place.


Make sure all of your codes are on the claim form to support the exception process. In SNFs, the UB92 claim form has limited space for ICD-9 codes. When submitting a Medicare B claim all of the medical diagnoses do not need to be on the claim, just the ones supporting the bill. Contact the business office and make sure that your discipline-specific intervention codes are listed on the claims submission. If you have KX modifiers on your treatments and the ICD-9 codes are not submitted, it will be denied.


Manual Requests to Provide Treatment Beyond the Cap
Manual requests to exceed the cap for those "conditions and complexities" not on the list can be submitted to your Medicare contractor. If a previous submission was denied, even though you indicated a correct ICD-9 on the list, you will have to submit documentation and a letter of justification to ask for no more than 15 treatment days. This is only for codes that are not are the list or have been denied. For the purposes here, dementias & Alzheimer's are on the list. Check source documents for further instructions or post a question on the DCS Online Community Forum.


Source documents:
Medicare Claims Processing Manual (ICD-9 exceptions list, starting on page 22)


Medicare Benefit Policy Manual, Pub 100-02 Chap 15 Sect. 220–230 (defines Maintenance Programs)


CMS listing of ICD-9 codes

As of January 1, 2006, the moratorium on a Medicare B financial limitation (Cap) expired. For the calendar year of 2006, the new annual limit on the allowed amount for outpatient physical therapy and speech-language pathology combined is $1,740 and a separate $1,740 for occupational therapy.