You may be able to secure an exemption from these caps. Physical therapy; Speech-language pathology services; Occupational therapy; If you meet Medicare’s eligibility requirements, Medicare covers therapy on a temporary basis to improve or restore your ability to function, or on an ongoing basis to prevent you from getting worse. The provider is newly enrolled or has not previously furnished therapy services. The CY 2020 proposed rule does not present any substantive changes to the therapy cap repeal, use of the KX modifier, or the targeted medical review process; rather, it clarifies and codifies the changes outlined in the Bipartisan Budget Act of 2018. However, PTs must continue to … Also, if your adjusted gross income is over $87,000 (or $174,000 for a couple), you will pay a monthly adjustment amount to Medicare in addition to your monthly Part D premium. Since January 1, 2018 there has been no exception process and you can no longer use a KX modifier for medically necessary services that exceed the cap. Our old friend, the “KX modifier threshold” formerly known as the Therapy Cap is unchanged. To find out how much your test, item, or service will cost, talk to your doctor or health care provider. 9 min. $2080. The Centers for Medicare & Medicaid Services (CMS) released the proposed FY 2021 Medicare Physician Fee Schedule (MPFS) Rule and Fact Sheet on August 3, 2020. Where you get your test, item, or service. Occupational therapy (OT) can help improve your physical and mental functioning. Although Medicare Part B covers some physical therapy services, it limits the amount of physical therapy you can receive. Physical Therapists’ Guide to the Therapy Cap In 2018, Medicare repealed its hard cap on physical therapy services. Despite a long-term force to cancel the cap, Congress lasted to renew the cap every year from its establishment. $2040. The original legislation did not clarify what services that are provided “in part” meant. The specific amount you’ll owe may depend on several things, like: Your doctor or other health care provider may recommend you get services more often than Medicare covers. CMS introduced the CO (OTA) and CQ (PTA) modifiers in the CY 2019 MPFS proposed rule. The therapy cap was planned as a provisional solution to regulate Medicare costs and was announced as part of the Balanced Budget Act (BBA) of 1997. However, PTs must continue to track their patients’ progress toward an annual threshold. You do not need to submit special documentation along with the KX modifier threshold. This helps us identify ads that are helpful to consumers and efficient for outreach. As long as the physical therapy is medically necessary and takes place at a participating provider, Medicare Part B typically covers 80% of the cost after you reach your deductible ($198 in 2020). Medicare Part B covers outpatient therapy, including physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT). For CY 2020, the KX modifier threshold amounts are: (a) $2,080 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and … You may be able to secure an exemption from these caps. This includes documentation that patients, based on their condition, require continued skilled therapy—ie, therapy beyond the amount payable under the threshold to achieve their prior functional status or maximum expected functional status within a reasonable amount of time. Although Medicare covers physical therapy, the services are not completely free. Therapy cap gone. Or, they may recommend services that Medicare doesn’t cover. Unlike with Part A, prior hospitalization is not a prerequisite for Part B to cover physical therapy. The provider is part of group that includes another provider identified by the above factors. Use of this and other APTA websites constitutes acceptance of our Terms & Conditions. This change from the earlier "hard" therapy caps is the result of the Bipartisan Budget Act of 2018 (BBA of 2018) which provides for Medicare payment for outpatient therapy services including physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT) services. Under Medicare Part B, the annual limitations on per beneficiary incurred expenses for outpatient therapy services are commonly referred to as “therapy caps” now known as KX modifier thresholds. Dec 1, 2020 . This is a rule is hot of the presses. The therapy cap limits for 2014 are: $1,920 for physical therapy (PT) and speech-language pathology (SLP) services combined; $1,920 for occupational therapy (OT) services; You may qualify to get an exception so that Medicare will continue to pay its share for your services after you reach the therapy cap limits. Don’t wait: Medicare Advantage Open Enrollment ends March 31, Sign Up / Change Plans. For CY 2020, the KX modifier threshold amounts are: (a) $2,080 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and (b) $2,080 for Occupational Therapy (OT) services. There used to be a therapy cap on how much Medicare would pay but the cap was lifted in 2018. Trending with previous years, the proposed final rule was late this year – coming in August instead of July when it normally comes in. The caps on the following Part B services for 2020 remain have increased, though if your therapist tells Medicare that more care is medically necessary and Medicare approves, you can go over the caps: outpatient physical therapy and speech-language pathology combined: $2,040 Selecting OFF will block this tracking. Last Updated : 09/10/2018 3 min read. This cap has been repealed and is no longer in effect. You may have heard about the Medicare physical therapy “cap.” Medicare Part B helps pay for medically necessary services, generally up to a certain limit or cap as described below. Medicare used to set an annual maximum for what it would pay for outpatient therapeutic services, but the cap was eliminated in 2018. Medicare provides coverage under Part B for various outpatient therapy services such as physical therapy (PT), occupational therapy (OT), and speech language therapy. Just as with the incurred expenses for the therapy cap amounts, there is one amount for PT and SLP services combined and a separate amount for OT services. The patient's condition, including the diagnosis, complexities, and severity. We take your privacy seriously. Physical therapy EMR software will need to accomodate the new Medicare therapy cap changes effective Oct. 1, 2012. Physical therapy continues to be a growing field with a positive outlook as a career path. Medicare Coverage of Physical Therapy. Beneficiaries of original Medicare won’t have to pay the full cost of outpatient physical, speech or occupational therapy because Congress permanently repealed the cap that has historically limited coverage of those services. Previously, Medicare only covered up to 80 percent of $2,040 ($1,608) for physical and speech-language therapy services and another 80 percent of $2,040 ($1,608) for occupational therapy services. No. These new modifiers are to be used on the claim line to identify services furnished by an assistant “in whole or in part” under an occupational therapy or physical therapy plan of care, starting in 2020, with the payment reduction being implemented in 2022. Whether you’re in an accident or you have a medical condition, therapy can improve the quality of life. For CY 2019 this KX modifier threshold amount is: $2,040 for PT and SLP services combined, and; $2,040 for OT services. For 2018 through 2028, the targeted medical review threshold is $3,000 for PT and SLP services, and $3,000 for OT services. For CY 2020, the KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined is $2,080. This helps us improve our social media outreach. Prev. Congress repealed Medicare therapy caps—the maximum outpatient speech-language treatment and occupational and physical therapy a beneficiary could receive per year—in February 2018 as part of the Bipartisan Budget Act of 2018. As a reminder, the Medicare Part B outpatient therapy cap (KX Modifier) amounts are updated and are $2,080 for occupational therapy, and $2,080 for physical therapy and speech therapy services combined for CY 2020. $2,040 for occupational therapy services. A proposal to cut 9% from Medicare payments for physical and occupational therapy under the federal government’s Proposed Physician Fee … PDF download: Medicare Claims Processing Manual – CMS. The Part B deductible applies; Medicare will pay its share once you’ve met your deductible for the year. Medicare used to set an annual maximum for what it would pay for outpatient therapeutic services, but the cap was eliminated in 2018. As the name implies, targeted medical review means that not all claims exceeding the therapy threshold amount are subject to review. $2080. KX Modifier Thresholds (formerly known as Therapy Cap Process) Under Medicare Part B, the annual limitations on per beneficiary incurred expenses for outpatient therapy services are commonly referred to as “therapy caps” now known as KX modifier thresholds. In making a decision about whether to use the KX modifier, consider, for example, whether services are appropriate to: Along with the KX modifier threshold, the BBA of 2018 retains the targeted medical review process that was established in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The “Medicare Program; CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies…” better known as the Proposed Rule has finally been published. Medicare Payment Thresholds for Outpatient Therapy Services, supplemental medical review contractor (SMRC), Medicare Claims Processing Manual, Chapter 5, Section 10.3.2, Outpatient Therapy Services and Advance Beneficiary Notice FAQs – Aug. 2018, 11 Part B Billing Scenarios for PTs and OTs (Individual vs. Group Treatment), Medicare Claims Processing Manual, Chapter 5 (Use of KX Modifier and Exceptions Process), Medicare Program Integrity Manual, Chapter 1 (SMRC), For Advertisers, Exhibitors, and Sponsors, $2,110 for PT and SLP services combined, and. Terms & conditions exceptions process MLN ) Matters ( MM ) 11532 diagnosis, complexities, audiologists! Media accounts, we may track what Medicare.gov content you share our content Facebook! Limits, also known as the therapy cap on Medicare ’ s coverage for physical therapy get!, it maintained the two key financial thresholds for therapy services—the “ KX ” modifier threshold and the review... 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