A Permanent Fix to the Therapy Cap: Improved Access for Medicare Patients Comes With Pending APTA-Opposed Cut to PTA Payment - PT in Motion News, 2/9/18
Under the Balanced Budget Act (BBA) of 1997 Congress placed an annual cap on rehabilitation services under Medicare. Since enacting the BBA, Congress recognized the cap's potential harmful effect on Medicare beneficiaries and acted several times to prevent implementation of a hard cap. However, these actions ended December 31, 2017, when the most recent extension of an exceptions process expired after Congress failed to pass a Medicare extenders package, which included a permanent fix to the therapy cap.
The 2-tiered exceptions process allowed for payment of medically necessary services beyond the cap threshold and comprised an automatic exceptions process and a manual medical review exceptions process. The automatic exceptions process applied when patients reached an initial cap threshold; providers attached the KX modifier to claims to identify those services. The manual medical review exceptions process was required at a second-level threshold. These exceptions expired December 31, 2017, per the Medicare Access and CHIP Reauthorization Act of 2015, which had extended the process through 2017.
In 2017, the Medicare Access to Rehabilitation Services Act (H.R. 807/S. 253) was introduced in the 115th Congress. H.R. 807 and S. 253 would permanently repeal the therapy cap imposed on physical therapy services. (The cap amount for 2018 is $2,010 for physical therapy and speech-language pathology services combined, with a separate $2,010 cap on occupational therapy services.) An arbitrary cap on outpatient therapy services without regard to clinical appropriateness of care discriminates against the most vulnerable Medicare beneficiaries. APTA believes that a full repeal of the therapy cap is necessary to ensure patients have access to timely and appropriate care.
January 29, 2018:
APTA joins patient and physician groups, and other stakeholders in submitting a letter to Congressional leadership calling on them to include the Medicare Therapy Cap fix, as well as other lapsed critical federal health programs, in the next spending bill that must pass by February 8.
January 27, 2018:
CMS provides notice that to minimize the impact of the therapy cap, it has held claims since January 1, 2018, that contain the KX modifier. Claims submitted without the KX modifier were paid if the beneficiary had not exceeded the cap but denied if the cap had been exceeded.
CMS says that starting January 31, it will begin releasing held claims on a first-in, first-out basis. Newly received claims with the KX modifier will be placed on a 20-day "rolling hold."
January 26, 2018:
APTA Issues a "Call to Action" for Patient Videos Therapy Cap – find out how you can get involved
January 22, 2018:
Government Reopens Under Short Term Deal That Leaves Medicare Patients in Limbo
January 5, 2018:
The Hard Therapy Cap Is Here: Answers to Some Common Questions
December 22, 2017:
Inaction by Congress Triggers No-Exceptions Therapy Cap in 2018
July 21, 2017:
APTA CEO Moore Testifies to Congress on Repeal of the Therapy Cap