On Wednesday, President Obama signed the Middle Class Tax Relief and Job Creation Act of 2012 (HR 3630), extending the therapy cap exceptions process for the remainder of 2012. The law mandates consistent use of the KX modifier upon reaching the $1,880 therapy cap and puts in place several reforms to the therapy cap policy.
Starting October 1, claims that meet or exceed $3,700 in annual therapy expenditures will be subject to a manual medical review. The $3,700 threshold will be applied to the combined physical therapy/speech-language pathology cap; a separate $3,700 threshold will be applied to the occupational therapy cap. Also starting October 1, each request for payment must include the national provider identifier of the physician who currently periodically reviews the plan of care. Additionally, HR 3630 designates that the therapy cap along with the exceptions process should apply to the hospital outpatient setting no later than October 1. This provision, along with the full exceptions process, will expire at the end of 2012 unless Congress chooses to extend them into 2013.
An information bulletin, podcast, and FAQs thoroughly outline these new provisions and also address 2 key reports mandated by the law to review methods to improve the outpatient therapy benefit and examine the manual medical review process.
It seems asinine to spend all this time rearranging, learning and then reconstructing the salary caps at the end of the year. APTA, ASHA and AOTA should be soliciting for repeal of the caps altogether and APTA and ASHA should be soliciting for separation of the caps if they should continue. The caps add administrative costs to all forms of outpatient care, are generally never reached (because many Medicare beneficiaries can't afford the copay and stop therapy early or the outcomes are achieved), and there is no meaningful data derived from the use of the codes that beneficiaries understand or improve clinical care. Congress needs to wake up!
Posted by Jim Haberstro, PT
on 2/24/2012 6:37 PM
Davis, I respectfully and strongly disagree. We are a community based practice and see any and all Medicare patients for everything from strokes to parkinson's, to bilateral total knee replacements as well as adult CP's, and many more with complexities that are numerous. These patients make measurable improvement and usually will exceed the cap. These are community dwelling functioning people who want to be able to continue to participate in life and society. The amount of work that is done to track and monitor the caps and the anxiety that it creates for our patients just adds to the complications and slows the progress. If there is abuse then the marketplace will take care of it as it always has! We need to be able to use our clinical judgement and do what is best for our patients. Health care practitioners, not administrators/congress/bureaurocrats, working with our patients and their caregivers should be determining the care and interventions!
Posted by Joan-Alice Taylor
on 2/27/2012 11:27 AM
I STILL wonder why the APTA, etc. hasn't asked for the reasoning as to why hospital out-patient services do not have to "live by the cap" as do private clinics, etc.? I see that, as of October, that will change, but hospitals have enjoyed that ability to treat complicated cases exhaustively without having to justify anything over the $1800 mark for years. And why wait until October?
Posted by M. Kovar, PT
on 2/28/2012 2:23 PM
Why is it that PT and speech are "still" combined under one $1880 cap, and OT has its own $1880 cap??? We all pay a good chunk of $ to the APTA to advocate for us (especially 2 PT families)...this seems like it should have been a priority??
Posted by John
on 2/29/2012 9:14 AM
Thank you for your continued interest in advocacy efforts to repeal the therapy caps. As always, APTA’s goal is full repeal of the therapy caps. The association’s advocacy for this issue is a year-round effort. In regard to this most recent exceptions extension, meetings regarding repeal of the caps and movement to an alternative payment system began in early 2011. Many provisions contained in this legislation establish a clear path to a new payment system that aims to eliminate the caps altogether. The Centers for Medicare and Medicaid Services (CMS) will work over the next several months to issue guidelines for providers to stay current with provisions outlined to start on October 1. APTA will post additional educational materials as meetings with the agency continue. In the meantime, it’s imperative that APTA members stay informed and active regarding ongoing efforts to repeal the caps and establish a new payment system for therapy. We encourage members to refer to existing resources, such as the therapy cap FAQ, podcast, and information bulletin that address many of the questions posted on this site. Moving forward, the active participation of APTA’s membership will be key in making gains related to cap repeal and all APTA advocacy efforts.
Posted by News Now staff
on 3/1/2012 12:36 PM