A PT’s Guide to the Therapy Cap
The Middle Class Tax Relief and Job Creation Act of 2012 (HR3630) impacted physical therapists in private practice in terms of the Medicare therapy cap. First and foremost, HR3630 extended the therapy cap exception process through the 2012 calendar year. Secondly, it requires that the Centers for Medicare and Medicaid Services (CMS) apply the therapy cap limitations to hospital outpatient departments no later than October 1, 2012. The therapy cap for hospital outpatient departments concludes at the end of 2012 unless Congress passes additional legislation extending it into 2013.
So how does this affect the private practitioner? Currently, any outpatient therapy a Medicare beneficiary receives in a hospital outpatient therapy department between January 1 and September 30, 2012, does not count towards the $1,880 physical therapy and speech-language pathology cap. However, beginning on October 1, 2012, any therapy a Medicare beneficiary receives in a hospital outpatient department will now count toward the cap. Additionally, any outpatient therapy the Medicare beneficiary received in a hospital outpatient department from January 1 to September 30, 2012, will be applied retroactively to the $1,880 therapy cap limitations beginning on October 1, 2012.
For example, a Medicare beneficiary receives therapy in a hospital outpatient department from March 5 through April 11, 2012, and July 20 through August 15, 2012, and uses $2,128 toward the Medicare therapy cap. That same Medicare beneficiary now comes to your private practice for outpatient physical therapy beginning on October 17, 2012. During the intake process, you ask the Medicare patient if they have had therapy at all this year. They answer “yes” and tell you XYZ hospital provided therapy during the aforementioned dates. Because the hospital provided therapy services prior to October 1, 2012, you believe the Medicare patient has not used any of their $1,880 therapy cap. On the contrary, those services ($2,128) will be retroactively applied toward the cap on October 1, 2012. Thus, the patient has already exceeded the allowed amount of therapy for the year. As the private practitioner, you would now need to append the KX modifier to each CPT code on the claim form, beginning with the initial date of service to ensure reimbursement for your services.
Furthermore, beginning October 1, 2012, you must include the physician’s National Provider Identifier (NPI) or non-physician practitioner (NPP) who certified the plan of care on the claim form. So how does that differ from what you do now? If the physician or NPP who certifies the plan of care is the same one who referred the patient for outpatient physical therapy, then there is no difference. However, there are times when one physician/NPP may refer the Medicare patient for outpatient physical therapy, yet a different physician/NPP signed the plan of care. Beginning October 1, 2012, CMS requires the physician or NPP who certifies the plan of care to include his or her NPI number on every claim form submitted for payment. As of today, we are still waiting for CMS to provide instructions as to where therapists should place this information on the1500-claim form.
It’s a lot to take in, I know. So, join me for the WebPT webinar Keep Your Clinic Compliant on August 21st or 23rd. In this free 60-minute session, I’ll discuss the therapy cap and the manual medical review process effective October 1.