No Therapy Cap Exception Process for 2018

December 22, 2017
Rick Gawenda

The United States Senate and House of Representatives have recessed for the Christmas Holiday without repealing the therapy cap or extending the therapy cap exception process. Congress will not return to Capital Hill until January 3, 2018.

So what does this mean for Medicare beneficiaries receiving outpatient therapy services in 2018 in a non- outpatient hospital setting and in a outpatient hospital therapy setting? There will now be a hard therapy cap dollar threshold of

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    1. It’s the allowed amount for each CPT code after the multiple procedure payment reduction has been applied but before the 1.6% sequestration reduction.

  1. If the Medicare beneficiary has a secondary insurance, is it likely the secondary insurance will continue to cover therapy if they exceed the therapy cap? Thank you.

  2. In addition to the exceptions process, MACRA extended the therapy cap to be applicable to both outpatient hospital and CAHs. So since MACRA expires on 12/31/17 does that mean the therapy cap no longer applies to outpatient hospital settings? I cannot seem to find that answer on CMS or APTA website anywhere.

    1. You are partially correct. Outpatient hospitals are exempt from the therapy cap but not critical access hospitals (CAHs) CAHs are not considered outpatient hospitals. I did update the article and provided a link to the Social Security Act for you to read.

  3. Will the therapy cap apply to Medicare Advantage plan members or just traditional Medicare beneficiaries?

    1. The therapy cap is for traditional Medicare Part B. Whether or not a Medicare Advantage (MA) plan implements a cap would be up to each MA plan to decide.

  4. You stated “A hospital outpatient therapy setting will be able to see a Medicare beneficiary above the $2010 therapy cap and be paid for those services and no KX modifier would be required.” For HODs then, are they able to go up to $3700 without a KX or beyond $3700?

  5. what happens to established pt’s that are above the $2010.00 going into 2018. Do they need to sign an ABN. are they allowed to con’t tx if necessary? are they responsible for any amount above the $2010.00?

    1. The therapy cap is a calendar year cap. On January 1, 2018, Medicare beneficiaries all start at zero dollars.

  6. When you say a hospital outpatient therapy setting, does that include hospital outpatient departments or just hospitals with ER, outpatient-bedded, short stay, or observation patients?

    1. Any outpatient therapy billed under the hospital NPI. This would include hospital outpatient therapy departments, but not critical access hospitals (CAHs). CAHs will have a hard therapy cap in 2018.

        1. Patients that are admitted into the hospital, have exhausted their Part A benefits and are having the therapy they are receiving billed under their Part B benefits, then this would apply to them as well.

      1. Where do CAH’s, which weren’t part of the original cap legislation, fall in these definitions from the Social Security Act if they’re not considered an HOD?

        A) outpatient physical therapy services, outpatient speech-language pathology services and outpatient occupational therapy services furnished—

        (i) by a rehabilitation agency, public health agency, clinic, comprehensive outpatient rehabilitation facility, or skilled nursing facility,

        (ii) by a home health agency to an individual who is not homebound, or

        (iii) by another entity under an arrangement with an entity described in clause (i) or (ii); and

        (B) outpatient physical therapy services, outpatient speech-language pathology services) and outpatient occupational therapy services furnished—

        (i) by a hospital to an outpatient or to a hospital inpatient who is entitled to benefits under part A but has exhausted benefits for inpatient hospital services during a spell of illness or is not so entitled to benefits under part A, or

        (ii) by another entity under an arrangement with a hospital described in clause (i), the amounts described in section 1834(k); and

  7. one advantage is there will be no sharing of dollars with speech for hospital based PT, private practice will still be sharing the cap amount??

  8. Hi Rick
    For hospital outpatient settings if the Cap is repealed when Congress returns, will the amounts be retroed back to January 1st? I’m trying to determine if we should go ahead and continue tracking the charges in case the repeal goes back to include hospital settings.

  9. I have read in the NYPTA newletter that the hard cap of $2010 does not apply to hospital OP therapy clinics? advice on how to proceed until Congress has made their decisions this month?

    1. Congress returns to Washington DC on January 3, 2018 and we will have to wait and see how fast they act to either repeal the therapy cap or extend the therapy cap exception process for 2018.

  10. Can you please cite where it states that the hard cap of $2010 does not apply to hospital therapy clinics? I have not been able to find this wording on the CMS website.

    1. You have the reference and link at the end of this article. Click on the link and read the Section that I mention.

    1. You would have to check with them to see if they have implemented a therapy cap. The therapy cap I speak about in this article is for traditional Medicare Part B therapy services.

  11. Our financial office is asking for a link to this information found on CMS so they have the exact Medicare language. Do you have that link? Thanks much!

    1. CMS has not posted it. The information is found in the reference I posted at the bottom of the article.

    1. The information in this article is current as of today. Congress returned to Washington DC today and we do expect this to change within the next 16 days.