Therapy Caps Exceptions Process Expired
Congress took no action in 2017 to extend the therapy caps exceptions process, which resulted in the expiration of this legislation as of December 31, 2017. As of the writing of this article, the therapy caps exceptions is no longer in place.
There is a hard cap of $2,010 on physical therapy and speech language pathology (PT and SLP) combined, and another hard cap of the same amount on occupational therapy (OT). Any Part B outpatient therapy services received by a Medicare beneficiary above the therapy caps are the responsibility of the beneficiary. This applies to all outpatient therapy providers including skilled nursing facilities (SNFs), rehab agencies, and independent therapists in private practice. Hospital outpatient departments revert back to being the exempt from the therapy caps with no exceptions process, unless Congress acts to change the legislation or repeal the therapy cap provisions altogether.
It is expected that Congress will retroactively reinstate the therapy caps exceptions process, but until that happens Medicare providers must follow the current law as it is written. There is no clear guidance from the Centers for Medicare and Medicaid Services (CMS) regarding operational procedures for those beneficiaries who have reached the cap but would qualify for the automatic exceptions process, if it were to be reinstated. It is recommended that these beneficiaries be given an Advance Beneficiary Notice (CMS-R-131) informing them that any additional therapy services they receive are not payable by Medicare. This notice would have to be issued for both caps, should the beneficiary exceed both the PT/SLP and OT caps.
Since therapy claims are often submitted monthly, it is likely that by the time the January claims are submitted, this issue will have been resolved. If it is still pending at that time, it is recommended that the KX modifier be attached to any services above the cap that would qualify for the exceptions process.
If you have any questions about the therapy caps legislation, please contact a member of Marcum’s Healthcare Advisory Group.