FAQ – Therapy Threshold

Question – Posted November 5, 2019

What additional and/or special documentation does CMS require to support outpatient therapy provided above the annual therapy threshold dollar amount in calendar year 2020?

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Question – Posted November 5, 2019

In a non-private practice setting, when should I append the KX modifier to CPT codes for services that have exceeded the 2020 therapy threshold dollar amount?

Answer

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Question – Posted November 5, 2019

I work in a private practice. When should I append the KX modifier to CPT codes for services that have either exceeded the 2020 therapy threshold dollar amount or the Medicare beneficiary is close to exceeding the therapy threshold dollar amount in 2020?

Answer

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Question – Posted November 5, 2019

In 2020, what is the targeted medical review threshold dollar amount?

Answer

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Question – Posted November 5, 2019

In calendar year 2020, what is the annual therapy threshold dollar amount for outpatient therapy services?

Answer

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Question – Posted October 6, 2019

What additional and/or special documentation does CMS require to support outpatient therapy provided above the annual therapy threshold dollar amount?

Answer

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Question – Posted February 17, 2018

In a non-private practice setting, when should I append the KX modifier to CPT codes for services that have exceeded the 2018 therapy cap dollar amount?

Answer

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Question – Posted February 17, 2018

I work in a private practice. When should I append the KX modifier to CPT codes for services that have either exceeded the 2018 therapy cap dollar amount or the Medicare beneficiary is close to exceeding the $2010?

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Question – Posted February 17, 2018

In 2018, must I append the KX modifier to outpatient therapy services provided above $2010 in an outpatient hospital and critical access hospital?

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Question – Posted February 17, 2018

Prior to the passage of H.R. 1892, outpatient hospitals were exempt from the therapy cap and did not need to worry about tracking therapy services and exceeding $2010. Since H.R. 1892 was signed into law on February 9, 2018, must outpatient hospitals start tracking therapy services towards the $2010 with dates of service on and after February 9, 2018 or back from January 1, 2018?

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Question – Posted February 17, 2018

In 2018, since the targeted medical review threshold dollar amount was lowered, does that mean more claims will be reviewed?

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Question – Posted February 17, 2018

In 2018, what is the targeted medical review threshold dollar amount?

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Question – Posted February 17, 2018

In 2018, if I forget to append the KX modifier to outpatient therapy services provided above $2010, what will happen to my claim?

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Question – Posted February 17, 2018

Does the therapy cap repeal apply to all outpatient settings?

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Question – Posted February 10, 2018

How does the annual Part B deductible impact the annual therapy cap dollar threshold?

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Question – Posted February 10, 2018

How is the Medicare allowed amount for each CPT code determined that is then applied to the annual therapy dollar threshold to determine when the KX modifier is required?

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Question – Posted February 10, 2018

In 2018, must I append the KX modifier to outpatient therapy services provided above $2010?

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Question – Posted February 10, 2018

In 2018, is there a therapy cap in place for outpatient therapy services?

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Question – Posted January 31, 2018

What is the 2018 Medicare Part B deductible?

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Question – Posted August 15, 2017

How do I get paid for services provided above the annual therapy cap dollar amount in 2017?

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Question – Posted August 15, 2017

Once a Medicare beneficiary reaches the annual therapy cap dollar amount in 2017, do I need them to sign an advance beneficiary notice of noncoverage to continue therapy services(ABN)?

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Question – Posted August 15, 2017

If a patient started therapy in December 2016 and continued thru to February 2017, would the January and February 2017 dates of service and payment apply to the 2016 therapy cap since the patient started this episode of care in 2016?

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Question – September 7, 2016

If a patient is in outpatient therapy and gets close to the $3700 threshold or goes over, is there a way we can get pre-approval/authorization from Medicare to go over the $3700?

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Question – Posted April 22, 2016

If a patient started therapy in December 2015 and continued thru to February 2016, would the January and February 2016 dates of service and payment apply to the 2015 therapy cap since the patient started this episode of care in 2015?

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Question – Posted November 11, 2015

Once a Medicare beneficiary reaches the annual therapy cap dollar amount in 2016, do I need them to sign an advance beneficiary notice (ABN)?

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Question – Posted November 11, 2015

How do I get paid for services provided above the annual therapy cap dollar amount in 2016?

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Question – Posted November 11, 2015

Is the therapy cap exception process in place for 2016?

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Question – Posted November 11, 2015

How does the annual Part B deductible impact the annual therapy cap dollar threshold?

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Question – Posted November 11, 2015

What is the 2016 Medicare Part B deductible?

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Question – Posted November 11, 2015

What dollar amount is applied to the therapy cap dollar amount threshold?

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Question – Posted November 11, 2015

How is the Medicare allowed amount for each CPT code determined that is then applied to the annual therapy cap dollar threshold?

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Question – Posted November 11, 2015

What is the Medicare therapy cap dollar threshold for 2016?

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Question – Posted December 12, 2014

Once a Medicare beneficiary reaches the annual therapy cap dollar amount, do I need them to sign an advance beneficiary notice (ABN)?

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Question – Posted December 12, 2014

How do I get paid for services provided above the annual therapy cap dollar amount?

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Question – Posted December 12, 2014

How does the annual Part B deductible impact the annual therapy cap dollar threshold in 2015?

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Question – Posted December 12, 2014

How does the government’s 1.6% sequestration reduction impact the therapy cap dollar threshold in 2015?

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Question – Posted December 12, 2014

What dollar amount is applied to the therapy cap dollar amount threshold?

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Question – Posted November 11, 2014

What is the status of the manual medical review process for Medicare beneficiaries who exceed $3700 in physical therapy and speech-language pathology services combined or a separate $3700 for occupational therapy services in 2015 ?

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Question – Posted November 11, 2014

Is there a therapy cap exception process in 2015?

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Question – Posted November 11, 2014

What is the therapy cap dollar amount for calendar year 2015?

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Question – Posted October 3, 2014

Do Medicare payments to a Home Health Agency impact the therapy cap?

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Question – Posted October 3, 2014

If I continue to bill a Medicare patient above and beyond the $3700, will that trigger an automatic medical review of the patient’s medical record by my Medicare Administrative Contractor or Recovery Audit Contractor?

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Question – Posted October 3, 2014

If I continue to bill a Medicare patient above and beyond the therapy cap dollar amount of $1920 in 2104, will that trigger an automatic medical review of the patient’s medical record by my Medicare Administrative Contractor?

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Question – Posted April 19, 2014

If a Medicare patient is evaluated and/or treated by PT, OT, and/or SLP in the emergency department of a hospital or while they are under observation status, is that considered outpatient therapy and would it apply to the therapy cap?

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Question – Posted April 19, 2014

Is therapy provided in a hospital inpatient setting, SNF Part A, or home health under a home health episode plan of care count towards the therapy cap?

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Question – Posted April 1, 2014 (Updated Answer)

What is the current status of the therapy cap?

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Question – Posted March 16, 2014

What is the current status of the manual medical review process for claims that exceed $3700

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Question – Posted March 16, 2014

What is the current status of the therapy cap?

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Question – Posted January 17, 2014

Our patient has a secondary insurance that will pick up as a primary when Medicare runs out. The secondary insurance carrier wants to see denials from Medicare in order to pay. The patient does have a diagnosis of difficulty walking so we can use the KX modifier. In order to bill his secondary, do we have to use the KX modifier or can we stop at the $1920 limit, get denied and then bill the patient’s secondary insurance?

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Question – Posted January 10, 2014

How does the 2014 Medicare Part B deductible impact the $1920 and $3700 therapy cap thresholds?

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Question – Posted January 10, 2014

How does CMS calculate the amount that gets applied to the $1920 and $3700 therapy cap thresholds?

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Question – December 21, 2013

Is there a manual medical review process for claims that exceed $3700 in PT/SLP expenditures and a separate $3700 for OT in 2014?

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Question – December 21, 2013

Will hospital outpatient therapy departments be under the therapy cap in 2014?

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Question – December 21, 2013

Will critical access hospitals be under the therapy cap in 2014?

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Question – December 21, 2013

Is there a therapy cap exception process in calendar year 2014?

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Question – December 21, 2013

What is the therapy cap dollar amount for 2014?

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Question – December 21, 2013

During your seminar you mentioned that the advance beneficiary notice (ABN) form is not used to notify a participant of nearing the Med B cap.  Is there another form or what do you recommend ?

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Question – September 10, 2013

Our hospital system has a wound clinic. It is staffed by nurses and an MD. They sometimes bill for debridement using the 97597 & 97598 CPT codes. They are not under the therapy cost centers so they do not use the 420 or 430 revenue codes for billing and the GN,GP,GO modifiers are not used. Would these services count towards the therapy cap?

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Question – August 15, 2013

My understanding was that when a Medicare beneficiary seeks outpatient therapy treatment beyond the $3700 limit, that an ABN is not necessary; however, we need to bill Medicare to obtain a denial so we can forward the claim to the patient’s secondary insurance. May we use the GA modifier to get the denial from the Medicare program?

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Question – August 15, 2013

I know home health does not have the therapy cap applied to it, but does the money billed out with home care apply to outpatient therapy?? So if a pt received 22 OT visits from a home care agency and is ready to start outpatient services, don’t we have to incorporate that dollar amount into our CAP?

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Question – June 18, 2013 – Updated

Which modifier do I need to use when filing claims above the cap that are not medically reasonable and necessary? Do I still use the –GY modifier?

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Question – June 18, 2013 – Updated

Is it permitted to use the KX and GA modifier on the same day on a Medicare beneficiary?

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Question – May 3, 2013 – Updated

When are therapists not required to issue an ABN for outpatient therapy services?

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Question – May 3, 2013 – Updated

When are therapists required to issue an ABN for outpatient therapy services?

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Question – May 3, 2013 – Updated

When a Medicare beneficiary reaches the therapy cap dollar threshold of $1900, is an advance beneficiary notice (ABN) required?

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Question – April 5, 2013

When a Medicare beneficiary reaches the therapy cap dollar threshold of $1900, is an advance beneficiary notice (ABN) required?

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Question – March 10, 2013 (Updated on March 31, 2013)

Is there a pre-authorization process in 2013 for Medicare beneficiaries who exceed $3700 in outpatient therapy expenditures for PT/SLP and OT?

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Question – Posted January 27, 2013

What is the therapy cap dollar amount for 2013?

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Question – Posted January 27, 2013

Is there an exception process in place for 2013?

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Question – Posted January 27, 2013

Are hospital outpatient departments under the therapy cap in 2013?

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Question – Posted January 27, 2013

Are critical access hospitals (CAH’s) under the therapy cap?

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Question – Posted January 27, 2013

How does the Medicare beneficiaries Part B deductible impact the therapy cap dollar threshold?

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