Therapy Cap RecapIf you’re a rehab therapist who treats Medicare patients, you’ve got a bevy of rules and regulations to follow and knowing all of them inside and out is a tall order, to say the least. If decoding government legalese isn’t really your thing, don’t worry—we’ve dedicated this entire month to serving up a smorgasbord of digestible, easy-to-understand guides on the important Medicare policies that apply to you. On today’s menu: the therapy cap.

As part of the Balanced Budget Act (BBA) of 1997, the therapy cap places an annual limit on the total amount of reimbursement Medicare will provide for each patient’s rehabilitation services. In 2013, that amount was $1,900 (up $20 from $1,880 in 2012) for physical therapy and speech therapy combined, along with an additional $1,900 for occupational therapy. Although the government has yet to finalize the 2014 Physician Fee Schedule Rule—which will lay out the details of next year’s cap amount and the regulations surrounding it—we’re not expecting any major changes from last year’s therapy cap rules.

Here are some more fast facts about the therapy cap:

  • It currently applies to services furnished in:
    • private practices
    • physician offices
    • skilled nursing facilities (Part B)
    • rehabilitation agencies (or ORFs)
    • comprehensive outpatient rehabilitation facilities (CORFs)
    • outpatient hospital departments—although it will no longer apply to outpatient hospital settings in 2014 unless Congress passes legislation
  • It does not reset for each diagnosis.
  • Examinations or re-examinations that establish the medical necessity of continuing treatment beyond the cap do not count toward the cap, even if the patient has already exceeded it. (But, if the patient receives treatment, the entire visit counts toward the cap).

Each time you get a new Medicare patient, it is crucial that you find out if the patient has received any prior therapy services during the current benefit period, as those services will apply to the cap. To calculate the patient’s “running total,” you can safely assign $80 to $100 per visit. If the patient is unable to provide you with his or her therapy services history, you can get it via CMS by:

  • Visiting the ELGA or ELGB screens within the Common Working File (CWF) on the HIQA screen (for providers who bill through fiscal intermediaries).
  • Contacting your Medicare contractor and requesting the necessary information (keep in mind that the amount that goes toward the limit reflects the date of claim receipt, not the date of service).

Now remember, the therapy cap isn’t necessarily the end-all, be-all of reimbursement for a particular patient—at least not according to 2013 rules. If you believe that continuing therapy is medically necessary and that the patient qualifies for an exception to the cap, simply attach the KX modifier and clearly document your reasons for continuing treatment. If you believe treatment beyond the manual medical review threshold ($3,700 in 2013) is medically necessary, either your Medicare Administrative Contractor (MAC) will notify you that you must submit the appropriate documentation to an assigned Recovery Audit Contractor (RAC) (if you are in a pre-payment review state) or you will continue to receive reimbursement until you submit the appropriate documentation to your RAC, who will determine whether the services are covered (if you are in a post-payment review state). In the latter scenario, you’ll have to reimburse Medicare if they deem the services in question as not medically necessary.

Finally, if you would like to continue treating a patient who has exceeded the cap but does not qualify for an exception, you can do so as long as the services are no longer medically necessary and the patient agrees to pay out-of-pocket—or through a secondary insurance—by signing an Advanced Beneficiary Notice (ABN). Whatever you do, absolutely do not attempt to “game the system” by working around the therapy cap in order to avoid having your exceptions rejected.

 

As soon as we get the final word on next year’s therapy cap policy, we’ll post all the details right here on the WebPT blog. In the meantime, if you still have questions about the cap, leave them in the comments section below.

Top of Mind, Top of Search: 4 Ways to Help Patients Find Your PT Practice Online - Regular BannerTop of Mind, Top of Search: 4 Ways to Help Patients Find Your PT Practice Online - Small Banner
  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.) Questions …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • Final Rule 2015: Here’s What You Need to Know Image

    articleNov 6, 2014 | 3 min. read

    Final Rule 2015: Here’s What You Need to Know

    The summary of this year’s Final Rule is hot off the presses, which means that—among other things—we now know the details regarding PQRS 2015. For those who have been following the PQRS saga since the program first came into being in 2007, it should come as no surprise that Medicare has yet again upped the ante for compliance. Based on the fact sheet CMS provided , here’s the scoop on this year’s reporting requirements: Eligible professionals who …

  • 9 Most Common Medicare Misconceptions for PTs, OTs, and SLPs Image

    webinarSep 8, 2016

    9 Most Common Medicare Misconceptions for PTs, OTs, and SLPs

    To say that Medicare regulations are confusing is an understatement. But, it’s not just the barely-readable government gobbledygook that throws providers for a loop; it’s also the fact that the rules are always changing. If you treat Medicare patients, we’re willing to bet you’ve been tripped up by at least one of these common misconceptions—maybe without even knowing it. And that could leave a nasty bruise on your practice’s bottom line—especially if you ever find yourself at …

  • The 2015 Therapy Cap: Same Story, Different Year Image

    articleNov 18, 2014 | 3 min. read

    The 2015 Therapy Cap: Same Story, Different Year

    With all of the blog space we’ve devoted to PQRS this month, it’s easy to forget that Medicare’s final rule addresses more than just our favorite four-letter acronym. But buried deep within CMS’s annual 1,000-plus-page behemoth of government jargon is one more major item of interest to those in the PT, OT, and SLP industries: the therapy cap. First, the good news: in accordance with the Medicare Economic Index (MEI), both cap amounts—the one for occupational therapy …

  • CMS’s Final Bow: The 2019 Final Rule Image

    articleNov 5, 2018 | 8 min. read

    CMS’s Final Bow: The 2019 Final Rule

    Last week, the Centers for Medicare and Medicaid Services (CMS) published its 2019 final rule . Clocking in at just over 2,300 pages, the final rule isn't exactly a light read—especially because the legal lingo can be harder to interpret than Shakespearean verse. Luckily, we have the script—with all its twists and turns—decoded and ready for you to review. Here's the synopsis of all the physical therapy, occupational therapy, and speech-language pathology Medicare changes for 2019: Out, …

  • The Definitive Medicare Part B FAQ for Outpatient PT, OT, and SLP Image

    articleOct 27, 2016 | 33 min. read

    The Definitive Medicare Part B FAQ for Outpatient PT, OT, and SLP

    In October, we hosted a webinar dedicated to the most common Medicare misconceptions . We received a lot of questions from the audience—so many, in fact, that we’ve organized them all into one huge FAQ. Scroll through and check them out, or use the link bank below to skip to a particular section. The Therapy Cap ABNs Modifiers Supervision Prescriptions and Certifications Cash-Pay Rules and Regulations Re-Evaluations Everything Else   The Therapy Cap If a patient reaches …

  • Common Questions from Our Medicare Open Forum Webinar Image

    articleOct 25, 2018 | 43 min. read

    Common Questions from Our Medicare Open Forum Webinar

    Earlier this week, WebPT President Dr. Heidi Jannenga, PT, DPT, ATC, teamed up with Rick Gawenda, PT—President and CEO of Gawenda Seminars & Consulting—to host a Medicare Open Forum . As expected, we received more questions than our Medicare experts could answer during the live session, so we've provided the answers to the most frequently asked ones below. Don't see the answer you're looking for? Post your question in the comment section at the end of this …

  • The Rehab Therapist’s Quick Guide to the 2016 Final Rule Image

    articleNov 4, 2015 | 6 min. read

    The Rehab Therapist’s Quick Guide to the 2016 Final Rule

    November is finally here, which means we here at WebPT can’t stop thinking about a juicy, flavorful, hot-out-of-the oven—Medicare Final Rule. While your tastebuds probably aren’t jumping with joy over the thought of chewing over a bunch of regulatory gobbledygook, the good news is that this year’s final rule shouldn’t be too tough to swallow (and if it is, you can always add more gravy). We’ve already picked out the most important pieces and served ’em up …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.