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  • Senate Doesn't Move on SGR Repeal: What's Next for Therapy Cap?

    The US Senate's decision to adjourn without taking up the sustainable growth rate (SGR) repeal bill passed by the House on Wednesday gives physical therapists (PTs) and their supporters more time to press lawmakers for a repeal of the Medicare outpatient therapy cap. That's the good news.

    The not-as-good news? The current extension for SGR and exceptions to the therapy cap expire on March 31, and the Senate doesn't reconvene until April 13.

    So where does that leave PTs—and patients—who could face a $1,940 limit on reimbursement on outpatient physical therapist services beginning April 1? And what about the SGR-related 21% cuts set to kick in?

    What you need to know about the March 31 therapy cap deadline
    The bottom line is that if a PT's patient in Medicare part B exceeds the $1,940 therapy cap after March 31 and Congress has not passed legislation extending the therapy cap exceptions process, Medicare will not pay for the services above the cap.

    Gayle Lee, JD, APTA senior director of health finance and quality, advises PTs to consider issuing an advance beneficiary notice of noncoverage (ABN) form to any patient likely to exceed the $1,940 cap after March 31, just in case.

    The ABN provides the patient with a warning that services may not be provided for under Medicare, and allows the patient to choose whether to continue treatment (and pay out of pocket) or to stop treatment before the cap is exceeded. Background information on the ABN (.pdf), as well as forms and instructions, are available online from the Centers for Medicare and Medicaid Services (CMS).

    "The ABN process is an important one until there is resolution on this issue," said Lee. "Having an ABN in place allows PTs to collect payment from the patient for services above the cap—if the ABN isn't issued to the patient, and Medicare doesn't pay the claim, the provider is liable for the services and can't collect payment from the beneficiary."

    Lee suggests that in addition to the ABN, PTs should consider waiting things out.

    "There is a strong likelihood that Congress will adopt legislation addressing the therapy cap in the coming weeks," she said. "In the interim, PTs may want to also consider holding claims that exceed the cap and give Congress the time to make changes."

    Where things stand with the SGR (and therapy cap) in Congress, including payment cuts
    On Thursday, March 26, by a 392-13 vote, the House approved a bill that would permanently end the SGR, and sent the legislation to the Senate. As reported earlier in PT in Motion News, the House bill does not include a permanent repeal of the therapy cap, instead extending the exceptions process through 2017. The separation of therapy cap repeal from SGR repeal is a "risky approach for Medicare beneficiaries," according to a coalition of organizations, including APTA, that has been advocating for an end to the cap.

    On Friday, March 27, the US Senate adjourned for its spring recess without taking up the bill, with Senate leader Mitch McConnell telling Reuters that "we'll return to it very quickly when we get back" on April 13. APTA is urging its members to capitalize on the break by redoubling efforts to contact senators and their staffs.

    Because no Senate action was taken on the bill and Congress has not approved a temporary "patch" to the SGR, Medicare payment rates are scheduled to be cut by 21% after March 31.

    Providers, however, may not experience those cuts. Recently, CMS issued guidance that under current law they hold claims for 14 calendar days—enough time to allow Congress an opportunity to reach agreement on both the SGR and therapy cap when members return.

    What happens now, and what you can do
    For APTA members, the uncertainty over what happens during the congressional break is tempered by the possibility that the extra time will lead to an even better SGR bill, one that includes an end to the therapy cap. But much will depend on grassroots efforts.

    "We believe there is a very real opportunity for a permanent solution," said Mandy Frohlich, APTA vice president for government affairs. "APTA will work with legislators over the next 2 weeks to push for a full repeal of the therapy cap in a final SGR package, but we need direct involvement from our members."

    APTA is offering assistance for members through both the association's legislative action center and the APTA Action App. The association also encourages members to reach out to patients and colleagues to make contacts as well, and provides a patient action center to help them.

    To add real-life urgency to the issue, APTA is also asking for members to contact its advocacy staff with their stories of how the therapy cap impacts their ability to provide adequate services to patients, and the risks involved with arbitrary limits on outpatient therapy reimbursements. Send your stories to advocacy@apta.org.

    "We're at a critical juncture," Frohlich said. "We need members to keep up the drumbeat with legislators."


    • The media is reporting this as the "doc fix". Can we get messaging out there about the "therapy fix"

      Posted by erik on 3/27/2015 8:19 PM

    • This is a disservice to the beneficiaries we serve. An arbitrary cap that has been kicked down the road for 17 years is a waste of time, effort and energy. The Seniors would be better served with a focus on quality, outcomes and satisfaction!

      Posted by Leigh Ann Frick on 3/30/2015 8:37 PM

    • There is a notice on LinkedIn quoting APTA is suggesting that providers hold their claims. Has this information been interpenetrated correctly? Do not bill Medicare Starting Tomorrow!! Not an April Fool's Day Joke.

      Posted by Berni Willis on 4/1/2015 9:54 AM

    • If the cap is not renewed at $3700 and reverts to $1970, is that effective jan. 1 2015 or for charges beyond March 31, 2015?

      Posted by Gary Souza on 4/1/2015 4:33 PM

    • My understanding from what I've read at the AMA site is that April 15 will be when the 21% decrease in Medicare payments to providers goes into effect if the Senate doesn't act immediately when they reconvene on April 13. This cut, reported by the AMA, will make physicians reconsider whom they treat. Reiterating what Erik posted, we therapists really need to get on it and call our Congress members. Personally, I call my Senators and Representatives every day and leave a message.

      Posted by Edie Watson on 4/1/2015 8:21 PM

    • Interesting the extension to the caps is proposed to extend til 2017, when the time-based units for Medicare reimbursement are expected to shift to a quality/outcomes based "merit system" of payment. I have to agree with Ms. Frick, it's probably a waste of time, and we need to begin exploring what the shift will mean, and how the bean counters will judge us since they have little medical training with which to do so.

      Posted by Kate on 4/3/2015 8:49 AM

    • SRG-Repeal needs to be passed so I can continue physical therapy for a torn rotator cuff and 3 repaired tendons. I still can not lift my arm over my head. My therapist and I have been working very hard together for me to regain the full use of my arm. Ten visits are not enough to give me the use I should have. SRG-Repeal is needed in order for me to continue working on full use of my arm. Lets please get SRG-Repeal passed. Thank you

      Posted by Catherine Carey on 4/6/2015 6:43 PM

    • My husband and I were in an auto accident on Jan. 27, 2014. He was hospitalized, went from rehab facilities and back the the hospital several times. He wasn't released to come home until April 15, 2014. His arm was crushed, contracted MRSA and consequently lost most of the use of his left hand. He was 65 at the time of the accident. Due to Medicare caps, his therapy had to be stopped. His Dr. ordered more therapy to begin in Jan. 2015. Again, due to caps, just as we are seeing progress again, we are having to stop his therapy. Please help us!

      Posted by Mary Ann Orndorf on 4/13/2015 1:06 AM

    • I have an incurable, untreatable disease and need pt to keep up my limited strength. We are elderly, have a fixed income and cannot afford pt on our own. Please DO NOT lower the cap! I need PT for quality of life!b

      Posted by victoria black on 4/13/2015 4:36 PM

    • I will have shoulder replacement surgery in June. I needed PT to help with pain and build up muscles, as much as I can. I have to stop now because I am very close to the cap. I also have had problems with my neck and all are connected. But, I now will attend therapy after the surgery. Before I went on disability, I had good PT coverage. Medicare is so unfair limiting to me. Please help me.

      Posted by Lynda D on 4/14/2015 8:09 PM

    • I thought ABN was not to be used if you were going to bill a KX modifier. If the repeal happens and we have signed ABN and then we turn around and bill KX modifier Becuase the exeption process gets extended how does that work? ABN states not medically necessary and KX modifier states you are saying it is Medically Necessary.

      Posted by Missy D on 4/16/2015 9:47 AM

    • I had a stroke Nov 2013,and my left arm /hand are immobilized.I am a sax player . Evertime I get going good on my therapy ,I am cut off due to the therapy caps. A stroke is a brain injury and needs extensive therapy in order to function .Please lift these caps so we can get the outpatient therapy we need .Kindest Regards , Greg Forde

      Posted by Greg on 5/28/2015 9:07 PM

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