2018 Therapy Cap as of January 29, 2018

The House of Representatives and the Senate have failed to act to pass legislation to either repeal the outpatient therapy cap or to extend the therapy cap exception process for Medicare beneficiaries receiving outpatient physical and/or occupational therapy as well as speech-language pathology services in calendar year 2018. So what does this mean for providers of therapy services and their Medicare beneficiaries who started receiving outpatient therapy services the first week of 2018 and continue those services this week (week of January 29, 2018) and may exceed the $2010.00 hard therapy cap? Here is the latest!

If a Medicare beneficiary began outpatient physical therapy and speech therapy on January 2, 2018 in the locality of Detroit, Michigan and attended 3 sessions per week (ie. Tuesday, Thursday and Friday), by January 25, 2018 (Thursday) , they would have had 11 sessions of each discipline. Lets say each session, the physical therapist billed 2 units of therapeutic exercise (CPT code 97110), 1 unit of gait training (CPT code 97116) and 1 unit of therapeutic activities (CPT code 97530) and the speech-language pathologist billed 1 unit of the treatment of speech, language voice, communication and/or auditory processing disorder (CPT code 92507). Using the locality of Detroit, MI, the Medicare allowed amount for these charges that would be applied to the combined physical and speech therapy cap of $2010.00 would be $183.60 each visit. Multiply $183.60 by 11 visits and the Medicare beneficiary would have used $2,019.60.

If these therapy services were being provided in a non outpatient hospital setting (ie. SNF Part B, rehabilitation agency, critical access hospital, home health doing Part B in the home, comprehensive outpatient rehabilitation facility, and a private practice), these providers would have to provide the Medicare beneficiary with an advance beneficiary notice of noncoverage (ABN) if they were going to continue with physical and/or speech therapy after the 11th visit due to the hard therapy cap of $2010 and no therapy cap exception process in place. Whether or not you continue to submit claims to your Medicare Administrative Contractor would be dependent on which option the Medicare beneficiary selected in Section G of the ABN form. Check out my ABN FAQs by clicking HERE.

In this situation where a Medicare beneficiary has reached the therapy cap in a non outpatient hospital setting and still requires therapy services, a Medicare beneficiary could continue with physical and/or speech therapy services at an outpatient hospital and have the medically necessary therapy services paid for by the Medicare program since outpatient hospitals are exempt from the therapy cap. In this situation, an ABN would not be required to be given to the Medicare beneficiary. To read the exemption for an outpatient hospital, click HERE.

The Centers for Medicare and Medicaid Services (CMS) has released guidance on their process for therapy claims submitted with the KX modifier. To access the CMS guidance, click HERE.

Click Here to access my 2018 therapy cap FAQs.