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  • Therapy Cap Breakthrough? Legislators Reach Bipartisan Agreement on Repeal

    Editor's note: An earlier version of this story indicated that the KX modifier would not be required for claims less than $3,000. This story has been updated to reflect that the modifier will be required to accompany all claims over $1,980.


     After 20 years of opposition from APTA and 17 years of 11th-hour congressional patches to an inherently flawed policy, the Medicare therapy cap may be on its way out for good.

    But nothing's certain yet, and there are many details still to be worked out.

    On October 26, APTA representatives attended a meeting on Capitol Hill during which lawmakers from the House Energy and Commerce Committee, the House Ways and Means Committee, and the Senate Finance Committee announced a bipartisan agreement to end the therapy cap. The road from proposal to actual repeal can be long, and success isn't guaranteed, but if the proposal survives it would represent a major victory for patients and the physical therapy profession.

    Details are still emerging, but the current proposal would eliminate the $1,980 hard cap on physical therapy and speech-language pathology services (as well as the $1,980 cap on occupational therapy) on January 1, 2018, with claims above the $1980 threshold requiring the KX modifier. At the same time, the threshold for targeted medical review would be lowered from the current $3,700 to $3,000 through 2027. While the threshold amount for medical review would be lowered, the US Centers for Medicare and Medicaid Services (CMS) would not receive any increased funding to pursue expanded medical review.

    In more potential good news for patients and the physical therapy profession, the proposal does not include prior authorization requirements, a provision that had been included in earlier repeal attempts.

    APTA staff are reviewing the proposal in detail, but according to APTA Vice President of Government Affairs Justin Elliott, the basics look promising. Repeal of the therapy cap has been a central focus of APTA's public policy efforts since the cap’s introduction in 1997.

    "This is an important step, particularly because this is a bicameral, bipartisan agreement between the House and the Senate," Elliott said. "That kind of backing provides very real momentum for the repeal effort."

    Crossing the finish line, however, is not a sure thing, and there are many details that need to be worked out, not the least of which is the need for legislators to identify "pay fors"—cuts and offsets that can be offered up to cover the increased costs that may be associated with elimination the cap, Elliott said.

    In a joint statement from the House and Senate committees involved in the agreement, leaders characterized the proposal as a "major breakthrough" that solves a serious Medicare problem.

    "Arbitrary caps on these important services have never made much sense, as it is an important medical service that can both help patients avoid surgery or, when surgery is needed, help them recover their quality of life," the leaders said. "Now we must shift our work to ensuring that this important policy is fully offset."


    • I would choose Physical THETAPY benefits over a Primary Care Doctor if my Co Pay was the same!!

      Posted by Dee paternoster on 10/28/2017 11:43 AM

    • Overall, this is great news. Would be nice to see the targeted medical review stay at $3,700 and not decrease to $3,000. Perhaps there is still opportunity to negotiate that piece and keep it at $3700 or even better, eliminate it all together.

      Posted by Rick Gawenda -> =IY`?L on 10/28/2017 1:15 PM

    • It came within a whisker of a single vote in passing last year but still is a little hard to believe! After 20 years the arbitrary cap on therapies actually has a fighting chance to be lifted? That's fabulous and a huge success for our patients! Congratulations are absolutely in order to all those in the legislative trenches who have not given up or given in, and deserve a great big collective thank you!

      Posted by John M.Typaldos, PT on 10/31/2017 7:24 AM

    • Great News! A huge THANK YOU to all who have continuously worked so hard.

      Posted by Stephanie Washington on 11/1/2017 7:38 PM

    • Sounds promising. Thanks for your diligence!

      Posted by Paula Adams on 11/2/2017 10:15 AM

    • Are any SD legislators working on getting rid of this cap?

      Posted by Julie Stroup on 11/2/2017 4:52 PM

    • I'm confused. I'm not sure how this bill helps our profession. I'm in private practice physical therapy and the way I see it Medicare beneficiaries have just lost 700$ of physical therapy services. Can someone explain? Thank you

      Posted by Mike Newby on 11/3/2017 11:24 AM

    • There has never been a limit to benefits as long as therapy is medically necessary. This is not going to change the necessity of the service. The therapy CAP's have been an administrative burden. Keeping track of the CAP's to append the KX is burdensome. Hopefully , this will be eliminated. If they want to review claims that exceed a threshold as long as medical necessity is documented there will continue to be payments.

      Posted by Angie Martin on 11/3/2017 2:20 PM

    • I would like to echo Mike Newby and go on to say, the KX modifier has enabled us to go beyond the cap ($1980) with minimal effects as long our documentation is what it should be. We have not had to go above the threshold ($3700) for quite a while, but when we did it seemed to be a lot of work. Looks to me like it's more of a loss than a gain. I may be missing something so please let me know if I'm wrong. Thanks

      Posted by Shay Winters on 11/3/2017 3:41 PM

    • Hi Mike Newby, I will try to shed some light. The govt. since 1997 has passed a “bandage” on this issue so patients could continue to receive treatment after the $1,980 limit. Additional benefits after the $1,980 limit was never a guarantee. It needed to be voted on every year or every other year depending upon how long it was extended. It could be taken away, and the $1,980 would be all the benefits available to the patient in a given year. The way I understand the article is the govt. will finally eliminate the uncertainly if the cap will be in place for the following year/s and the patient will be guaranteed $3,000/$3,700 in benefits for a given year. If you have other questions, I would be more than happy to answer. I can be found at therapybillingservice.com

      Posted by Therapybillingservice.com on 11/5/2017 12:14 AM

    • Hi Mike. 50% of the patients give up at $1900 and don't finish their programs for fear of having to pay. The profession does better when the patients meet their goals.

      Posted by Alex Gometz on 11/5/2017 5:36 AM

    • Thanks for the input.

      Posted by Mike Newby on 11/7/2017 8:30 AM

    • Would the new threshold disassociate PT from SLP? If so, that is a bigger win in my mind, especially thinking of my neuro patients.

      Posted by Josh Lindblom on 11/8/2017 5:00 PM

    • So is this an overall gain or loss? The APTA put out an article that the Medicare cap was raised to $2,010 but made no mention of the $3,000/3,700 limit was mentioned within this article. If the cap was only raised by $30 (and thus still a cap) and the upper limit was dropped to $3,000 then I take this as a complete loss.

      Posted by Matt on 11/8/2017 5:12 PM

    • I see it as a gain If this passes, the threat of the hard cap (without ANY exceptions) goes away forever. The $2,010 would simply be a threshold to utilize a modifier to denote medical necessity. The $3,000 is not a limit/cap - but if you go over $3,000 then you could potentially be a candidate for medical review, because CMS is not going to review everyone who goes over $3,000.

      Posted by Mark on 11/10/2017 11:55 AM

    • very informative

      Posted by Geetha Murli on 11/15/2017 5:10 PM

    • Thank you APTA for fighting hard to allow our patients access to services. I would like to echo those above requesting separation of SLP and PT services. That said, it seems unnecessary to declare an annual cap amount, after which modifiers need to be added. The entire process would be simpler by CMS stating that services must be medically necessary and will be reviewed in excess of $3000.

      Posted by Marsha Lawrence -> ?GQ_? on 11/23/2017 12:25 PM

    • In my outpatient practice, I see almost no benefit to this news. I am always confident using KX modifiers to justify passing the $1980 cap. This will, in fact, negatively affect our ability to treat more difficult patients or patients with multiple treatment areas because now they are more likely to hit the $3000 mandatory review process; a process in which I am not interested in participating. Frankly, I greatly appreciate all the hard work put into this legislative process by APTA, but I see this as a net negative. It's a shell game. Please rescue me from third party payers.

      Posted by Anthony Cuoco on 11/25/2017 11:34 AM

    • I just read that the medicare cap was eliminated as of Feb. 2018 with the president signing this into law. Can someone please update me on when this would go into effect and would we still have to use the KX modifier? Thank you. Joanie Scott

      Posted by Tammy Patrick -> AGR_C on 4/26/2018 4:35 PM

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