• News New Blog Banner

  • CMS Clarifies Therapy Cap Exceptions for Critical Access Hospital Patients

    In a meeting with APTA yesterday, the Centers for Medicare and Medicaid Services (CMS) clarified the impact of the therapy cap on patients who receive outpatient therapy services in critical access hospitals (CAHs). CMS stated that for 2013, when a patient receives outpatient therapy services from a critical access hospital, the services will count toward dollars accrued toward the therapy cap. For example, if a  patient receives $2,000 of outpatient therapy services in a CAH and upon discharge goes to a private practice to continue therapy services, the private practice would need to obtain an exception (in this case use the KX modifier).

    However, CMS clarified that for 2013 the therapy cap does not apply to outpatient therapy services provided within CAHs themselves. This means that if the patient continued treatment in the critical access hospital, after exceeding $1,900 in therapy services, there would be no need to seek an exception through the automatic process. That is, the CAH would not need to submit the claim with a KX modifier. Also, if the patient exceeds $3,700 and continues care in CAH, the hospital would not need to obtain an exception through the manual medical review process.

    APTA had been seeking clarification on this issue from CMS since the January 1 passage of the American Taxpayer Relief Act of 2012 (HR 8), which extended the current 2-tier therapy cap exceptions process through 2013. The agency advised APTA last month that it was working with its general counsel for interpretation of the legislative language.   


    • And the double standard continues in the name of higher costs.

      Posted by Kirk on 2/8/2013 4:56 PM

    • Really? So once again private practice PT's take it in the shorts................

      Posted by Sue Jeffrey on 2/8/2013 5:01 PM

    • This is great - could you answer a further point for us? If the patient has already met their cap at a private practice or other outpatient facility that is not a CAH, and later in the year comes to outpatient therapy in a CAH,would the CAH need to ask for the cap exception through the established process? I am in a CAH and we would need to learn the cap exception process if this is required.

      Posted by Beverly Hasson on 2/8/2013 5:32 PM

    • So, if I understand this correctly, the independently owned free standing outpatient PT office gets strapped with the extra paperwork. What is the reasoning?

      Posted by Clayton on 2/8/2013 6:05 PM

    • Everyone has issues, regardless of the setting, and we all believe that the other guy has it better than we do.for example, a critical access hospital may not deal with the therapy cap, but when a federally insured patient chooses our facility to receive care the have a $75.00 copay, and if they seek services at a private clinic it costs $25.00. Also, if an insured patient on an anthem compass plan chooses a private clinic over our facility, they get a check for$150.00. We have higher costs, because as a facility we have to treat pele in many other areas of the hospital who know and we know will never pay for those services, and therefore we have to try to make up those costs in other departments ie: rehab, lab, radiology, so that at the end of the year we can keep the doors open. Certainly not a perfect system, but as I said we all have issues that we believe have merit!

      Posted by Derek on 2/8/2013 10:13 PM

    • What about patients who received physical therapy in an outpatient setting and then present to the ER in a hospital!? If the patient is placed in an outpatient or observation status; meeting no criteria for full inpatient admission and have met the therapy cap; if a physical therapist is consulted to evaluate that patient; do we as acute care therapists need to attach a KX modifer?

      Posted by Marlene Noll -> =NT^DL on 2/8/2013 10:36 PM

    • This is more than just a private practice vs hospital based payment system. Being in the Chicagoland area this affects none of our patients. This will not affect a majority of private practices unless they practice in the rural areas. We all (hospital based OP included) slighted, but these are people with little access to care and it is hard to argue against this ruling. If we could police ourselves as a profession and eliminate wasteful spending, this would not be the issue that it is today.

      Posted by Vincent on 2/8/2013 10:59 PM

    • There is no setting where this ruling has merit. With or without private practice in a critical access area it alienates and discriminates against private practice PT. If the goal was to increase services in a critical access why not include the private practicePT?No sense

      Posted by Tom Brocato on 2/9/2013 8:29 AM

    • I agree that there is always room for elimination of wasteful spending in our profession, I am still so relieved for my Medicare patients at my CAH that have multiple health issues that require long therapy in order to truly do them service.

      Posted by Ali Loraine on 2/9/2013 8:52 PM

    • No offense to you CAH PTs, but a CAH is not the only place MC patients with multiple issues get better with long term PT. Glad though some PTs can provide services without caps restraints. Just shows more discrimination within the PT cap debate. Can't do it here, but can over here..??All PT in critical access area should be included in CAH PT cap ruling. Isn't access for medical needy the real issue?

      Posted by Tom Brocato on 2/10/2013 8:43 AM

    • My practice is located in an underserved rural area. The reimbursement made to CAH PT/OT is based in large part it's cost report at 101% of cost for Medicare beneficiaries. This puts us at a severe disadvantage coupled with the prejudicial cap requirement. Comments above echo the double standards that exist.

      Posted by Ray Tresemer on 2/11/2013 8:41 AM

    • Derek, You make a great point. You have higher costs due to treating a bunch of people who cannot pay. Private practices are small businesses unencumbered by unions; do not have a bloated administration and their salaries; but PP does still pay taxes. In a normal consumer situation, the consumer would go to PT-owned PP because it's cheaper and the patient gets at least an equal quality of care. But in Bizarro world, our government chooses to tilt the scales toward a tax-free business group with a long history of questionable billing practices.

      Posted by Sean on 2/11/2013 3:00 PM

    • As a private practice owner, I pay for all my PT's APTA dues. I expect the APTA to go to bat for us in private practice. I work in a rural area where the therapy cap has a large impact on us. Come on APTA, help us out.

      Posted by Najib Johnson on 2/13/2013 10:49 AM

    • First, it is not just private practices that have a cap but also all hospitals other than critical access. And, medicare is not denying treatment when the cap is reached, just requiring that you show medical necessity. Please remember that Critical Access hospitals are still held to the same standards of showing medical necessity for treatment. They can not continue to see patients indefinitely just because there isn't a cap ! Last, I would venture a guess that most private practices limit the number of Medicaid/care patient they take on where as hospitals are not able to do that and subsequently carry a very high Medicaid caseload (which we all know we lose money on).

      Posted by chris on 2/20/2013 9:37 AM

    • There is no difference in the CAH or the private practice patients in rural areas that need access. So, no cap for the CAH, what if they don't provide the same quality of care as our private practice. The patient no longer has the RIGHT to choose who provides their therapy!!Double standard, no other way to look at it.

      Posted by Scott on 6/28/2013 6:12 PM

    • I've lost trust in the integrity of PPs billing and practice methods. Hospital PT is better for all.

      Posted by Dan Lanari -> BKS]?M on 11/27/2013 11:00 PM

    • Managing services in a CAH, I feel our metro and PP colleagues pain. Looking back we have very few patients who would actually hit the $3700 cap. The true burden to me is the man-power it takes to track these things takes away from the focus on patient care. Hopefully the APTA and CMS will agree on fair and equitable reform of reimbursement.

      Posted by FJ on 2/8/2014 8:32 AM

    Leave a comment
    Name *
    Email *