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  • Legislation Includes Cap Exceptions Process With Provisions, Extends GPCI

    Today, the House of Representatives and Senate passed legislation to prevent a 27.4% payment cut to Medicare providers scheduled for March 1 and extend several other Medicare policies important to physical therapists. The measure extends the Geographic Practice Cost Index (GPCI) at the current level for the remainder of the year and includes a 10-month extension of the therapy cap exceptions process that will begin to create a path to a reformed therapy payment system.  

    Physical therapists will continue to use the KX modifier at the $1,880 cap for 2012. However, new provisions have been added to the cap exceptions process. Starting October 1, claims for patients who meet or exceed $3,700 in therapy expenditures will be subject to a manual medical review. The legislation designates that this medical review will be similar to the process used following implementation of the Deficit Reduction Act in 2006. The $3,700 threshold will be applied to a combined physical therapy and speech language pathology cap. A separate $3,700 threshold will be applied to the occupational therapy cap. Also beginning October 1, each request for payment must include the national provider identifier of the physician who reviewed the plan of care. In addition, the therapy cap with exceptions will apply to hospital outpatient departments no later than October 1 until the end of 2012. This provision will sunset at the end of 2012 unless Congress extends it into 2013. APTA will work with the Centers for Medicare and Medicaid (CMS) to determine the agency's plans for implementing this and other provisions contained in the legislation.

    The bill also calls for the Medicare Payment Advisory Commission to submit recommendations by June 15, 2013, to the House Energy and Commerce Committee, House Ways and Means Committee, and the Senate Finance Committee on ways to reform the payment system to ensure that the benefit is better designed to reflect individual acuity, condition, and therapy needs of the patient. The report will examine private sector initiatives related to outpatient therapy benefits.

    The committee's measure also directs the Department of Health and Human Services (HHS) to implement a claims-based data collection strategy to assist in reforming the Medicare payment system for outpatient therapy. The system will be designed to provide for the collection of data on patient function during the course of therapy services in order to better understand patient condition and outcomes. In proposing and implementing such a strategy, HHS will consult with relevant stakeholders.

    In addition, the General Accountability Office will issue a report by May 1, 2013, to the House Committee on Energy and Commerce, the House Ways and Means Committee, and the Senate Finance Committee on the implementation of the manual medical review process. The report is to include data on the number of beneficiaries and claims subjected to the process, the number of reviews conducted, and the outcome of the reviews.

    The bill will be sent to President Obama for signature. APTA staff will reach out to CMS in the coming weeks to begin a dialogue about implementation of this legislation and will provide further information to membership regarding guidance and timelines for these new provisions.

    APTA is analyzing this legislation and will provide more resources as they become available.


    • Is physical therapy still combined with speech therapy for the cap? And is OT still the same cap?

      Posted by James M. Montana, PT, DPT on 2/17/2012 3:14 PM

    • In last evenings Legislative Report it mentioned that the cap would be extended to include Outpatient Hospital Departments. Is this accurate ?

      Posted by Brett McCormick on 2/17/2012 3:22 PM

    • Amen! Finally they can't keep taking away from the older population that need care the most. Thank you to all PT's who have worked on this bill :)

      Posted by Renee on 2/17/2012 3:36 PM

    • This is great news! (BTW: James and Brett, your questions are addressed in the second paragraph of the article.)

      Posted by Steve on 2/17/2012 4:02 PM

    • From 2nd paragraph: "Starting October 1, claims for patients who meet or exceed $3,700 in therapy expenditures will be subject to a manual medical review." Is this an annual threshold? Does it combine expenditures for PT, OT and SLP? Thanks!

      Posted by Maria on 2/17/2012 4:23 PM

    • Why is the PT and ST cap still combined?

      Posted by Martha Fiddes on 2/17/2012 4:49 PM

    • Is there a link to the source that talks about the $3700 cap beginning 10/1/2012? I just finished reading the bill from the Library of Congress and it section 3002 relating to the therapy cap has no mention of this $3700 cap.

      Posted by Leigh on 2/17/2012 5:12 PM

    • So, we’ve postponed the threatened cut for another year. If memory serves correctly this provision stems from the Balanced Budget Act circa 1991. With each year and increase in Medicare payment the “cut” needed also increases. Will there be the threat of a 30% cut next year? What is being done to finally remove this annual threat? Am I missing something?

      Posted by Herb on 2/17/2012 8:48 PM

    • Once hospitals fall under the cap will the MPPR reduction be the same as private practices?

      Posted by Stephanie Engelberg on 2/17/2012 11:23 PM

    • I beleive the KX $$ spent per beneficiary as a limit had already been implemented end of last year as one of the criterias of pre payment reviews.

      Posted by Cassius on 2/18/2012 11:34 AM

    • Do the new provisions added to the cap exceptions process likely mean fewer Medicare visits for PT?

      Posted by Wade Meyer -> >JXcBN on 2/19/2012 2:28 PM

    • Does anyone know if hospitals will be subject to the same reimbursement as private clinics in the same geographical area?

      Posted by Darin McCarthy PT, OCS on 2/20/2012 10:37 AM

    • Why is legislation such as this attatched to payroll tax legislation?

      Posted by Mary Stout -> =LYaC on 2/20/2012 2:34 PM

    • I have been unemployed for months awaiting this decision to be handed down before employers can safely hire me. Now this safety appears to last less than a year. Guess I cannot plan to have a job more than a few months, even though I'm in the top 20% of my field. This has to be stabilized!

      Posted by patrick tierney pta on 2/20/2012 7:04 PM

    • it's about time that hospital outpatient departments have to follow the same medicare rules as the rest of us. maybe we as a profession will make patient less dependent on us of have them take responsibility for their health.

      Posted by robert pt on 2/21/2012 7:29 PM

    • Could you please advise where on the CMS website it references the Cap Excetions process with provision, that indicates that there will be a medcial review after $3700 is reach for pt or ot. Medicare when called indicates that there is nothing in affect for this or listed on there website and can give me no information.

      Posted by Michelle Justice on 4/18/2012 9:12 AM

    • The legislation requires the manual medical review to begin by October 1. CMS has not yet issued instructions on when or how it intends to implement the this or other provisions contained in the legislation. APTA will post updates via News Now as this information becomes available.

      Posted by News Now Staff on 4/18/2012 1:55 PM

    • Could someone tell me why the OT cap is separate from the physical therapy and Speech therapy??

      Posted by Michelle on 4/10/2014 10:00 PM

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