Introduced as part of the Balanced Budget Act (BBA) of 1997, the therapy cap was intended as a temporary solution to control Medicare costs. However, despite a longstanding push to repeal the cap, Congress continued to renew it each year after it was first established. But in 2018, the hard cap was finally repealed—and replaced with a soft cap (a.k.a. an annual threshold amount). That means therapists must continue to track their patients’ progress toward the threshold each year—and affix the KX modifier to all claims for medically necessary services that exceed this threshold (in 2019, the threshold is $2,040 for PT and SLP services combined and $2,040 for OT services). Just like the cap, the threshold does not reset for each diagnosis; so, even if a patient seeks therapy related to multiple diagnoses over the course of the benefit period, all of those services count toward that patient's threshold. Still, the threshold is not intended to prevent Medicare patients from obtaining medically necessary care.
Now, given that much of the process for navigating the therapy threshold remains the same as it was before the hard cap repeal, some providers may be wondering whether this repeal is actually a step in the right direction. Well, consider this: every year since the cap’s inception, Congress voted in favor of an exceptions process to make it possible for physical therapists to continue providing Medicare beneficiaries with medically necessary services above the threshold—and receive payment for them. That said, every year, Congress could have just as easily decided not to vote in favor of an exceptions process—and therapists and patients would have suffered for it. With this repeal, the threat of a hard cap is gone.
Which services count toward the therapy threshold?
According to CMS, the therapy threshold applies to all Part B outpatient therapy services furnished in:
- private practices
- physician offices
- skilled nursing facilities (part B)
- rehabilitation agencies (a.k.a. outpatient rehabilitation facilities or ORFs)
- comprehensive outpatient rehabilitation facilities (CORFs)
- home health agencies (type of bill [TOB] 34X)
- critical access hospitals
- hospital outpatient departments (HOPDs)
- outpatient hospitals, as determined by:
- TOB 12X, 13X, or 085X
- Revenue code 042X, 043X, or 044X
- Modifier GN, GO, or GP
- Dates of service on or after January 1, 2014
Beginning in 2014, the therapy cap—along with the rules governing the exceptions and manual medical review processes—applied to critical access hospitals in the same manner as all other settings. So, if a patient continues treatment in a critical access hospital, the CAH will need to follow the rules of the soft cap exceptions process (as explained later in this guide) once that patient exceeds the therapy threshold.
How do I calculate a patient's progress toward the therapy threshold?
Each time a new Medicare patient comes to you for treatment, it’s crucial that you determine whether the patient has received any other therapy services during the current benefit period, as those services would apply to the threshold. To calculate the patient's "running total" toward the therapy threshold, you can reference the allowable fee schedule. In the event that the patient can't provide you with a history of the therapy services he or she has received, you can request this information from CMS by contacting your Medicare contractor. (Keep in mind that the amount that goes toward the limit reflects the date of claim receipt, not the date of service).
What is the therapy threshold exceptions process?
Automatic Exceptions (KX Modifier)
The therapy threshold is not the end-all, be-all of reimbursement for a particular patient. If you believe that continuing therapy with a patient is medically necessary—thus qualifying the patient for an exception to the threshold—then all you have to do is attach the KX modifier to the claims that exceed the threshold and clearly document your reasons for continuing treatment. This is known as the automatic exceptions process. There’s no need to submit additional documentation or supplemental forms to use the KX modifier, but by attaching the KX modifier to a claim, you attest that the services billed:
- qualify for the threshold exception;
- are reasonable and necessary;
- require the skills of a therapist; and
- are justified by supporting documentation in the patient's medical record.
You can use the automatic exceptions process to treat beyond the threshold until the patient reaches a total of $3,000 worth of treatment for the current benefit period. For claims that exceed that amount, providers should continue to affix the KX modifier; however, these claims are subject to a targeted medical review.
Targeted Medical Review
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) replaced the manual medical review process for claims that exceed the upper threshold with a targeted review process. As we explained here, “Despite the fact that the review threshold was reduced from $3,700 to $3,000 [in 2019], we do not expect to see an increase in reviews. After all, Congress did not increase funding for claim reviews.”
And not all claims that exceed the threshold will be targeted for review. Instead, “CMS's Supplemental Medical Review Contractor—Noridian Healthcare Solutions, LLC—will be selecting claims above the threshold to review based on these criteria:
- “The provider has a high claims denial percentage.
- “The provider has a pattern for aberrant billing or questionable billing practices (for example, billing medically unlikely units of services in a day).
- “The provider is newly enrolled as a therapist—or has no previously submitted claims for therapy services.
- “The services are furnished to treat a type of medical condition.
- “The provider is part of a group that includes another provider whose claims were flagged for review.
Losing your mind over modifiers? Watch our Modifier Open Forum webinar to learn how and when to use them.
What is an Advance Beneficiary Notice (ABN) of Noncoverage?
If you would like to continue therapy for a patient who has exceeded the threshold but does not qualify for an exception, you can do so through the use of an Advance Beneficiary Notice of Noncoverage (ABN)—along with the GA modifier, which we’ll cover in the next section. This allows a patient to keep receiving therapy that is no longer medically necessary. Essentially, an ABN notifies a Medicare patient that Medicare might not cover the therapy services he or she is about to receive—and serves as proof that the patient understands his or her financial obligation. By signing an ABN, the patient agrees to pay for treatment out-of-pocket or through a secondary insurance.
You must issue an ABN:
- Before providing items or services that you believe or know Medicare may not cover.
- Before providing items or services that Medicare usually covers but may not consider medically reasonable and necessary for a specific patient in a specific case.
In neither case can you issue an ABN after Medicare has already denied a claim—nor can you issue a blanket ABN to cover your bases with Medicare patients who may or may not end up needing one. Additionally, you must always have patients sign the ABN form before you provide the services in question.
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National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) employ different definitions of "reasonable and necessary." As a provider, you are responsible for knowing the current NCDs and LCDs governing your practice. In general, though, the medical necessity of services is determined based on:
- Whether the cost of treatment is reasonable considering the patient’s chances of reaching a desired level of relief or functional improvement.
- Whether the treatment will mitigate the patient’s risk of suffering an even worse outcome if the current condition is left untreated.
To shed light on the meaning of medical necessity and how it applies to physical therapists, the APTA released the Defining Medically Necessary Physical Therapy Services position in 2011. As described in that statement, “physical therapy is considered medically necessary as determined by the licensed physical therapist based on the results of a physical therapy evaluation and when provided for the purpose of preventing, minimizing, or eliminating impairments, activity limitations, or participation restrictions.” Furthermore, physical therapy treatment is considered medically necessary “if the type, amount, and duration of services outlined in the plan of care increase the likelihood of meeting one or more of these stated goals: to improve function, minimize loss of function, or decrease risk of injury and disease.”
This description might not match up with every single “medically necessary” definition out there, but it does speak directly to rehab therapists better than most communication on the subject. It also seems to align with Medicare’s payment requirements, especially with respect to the 2013 court decision that clearly discarded patient improvement as a condition of payment.
If you conclude that certain services are not medically reasonable and medically necessary based on the definition that applies to you—and thus, you issue an ABN—then you should add the GA modifier to the claim to signify that you have an ABN on file. (Please note that if you are using the GA modifier, you should not use the KX modifier.) You will still continue to submit claims to Medicare, but the GA modifier will prompt Medicare to reject them. Then, once you receive Medicare's denial, you can go ahead and collect out-of-pocket payment.
Remember, you should not issue an ABN for every beneficiary who exceeds the therapy threshold—only ones for whom the services in question do not fall under Medicare's definition of "reasonable or necessary." If you believe the services are medically necessary, you should instead follow the therapy threshold exceptions process as directed above. You might be tempted to issue blanket ABNs to ensure payment no matter what, but again, you absolutely should not engage in this practice. Medicare strictly prohibits providers from issuing ABNs on a regular, routine basis.