In 1997, Congress passed the Balanced Budget Act that created an annual financial limit on physical therapy and speech-language pathology services, and a separate "cap" on occupational therapy, for all outpatient settings, originally with an exemption for hospital outpatient departments. This action was not based on data, quality-of-care concerns, or clinical judgment—its sole purpose was to save resources needed to balance the federal budget. In 2012, Congress also directed the Centers for Medicare and Medicaid Services (CMS) to implement a review process for therapy services that exceed $3,700. Congress also directed CMS to apply this new 2-step exceptions process to the hospital outpatient department. In 2013, the annual per beneficiary therapy cap amount is $1900 for physical therapy and speech language pathology services combined and there is a separate $1900 amount allotted for occupational therapy services. Claims for patients who meet or exceed $3700 in therapy expenditures will be subject to a manual medical review. The following resources are related to the therapy cap and manual medical review process.
If you have questions about this information, contact advocacy@apta.org.
General Information
Take Action
- Medicare Therapy Cap Advocacy Efforts
Learn more about how you and your patients can make a difference in efforts to stop the therapy cap.
- Manual Medical Review Complaint Form
If you are experiencing issues with the Medicare therapy cap exceptions process for 2012 or other issues related to the therapy cap and you have been unable to resolve your issues by contacting your Medicare Administrative Contractor (MAC), you may complete this complaint form. APTA staff will contact you within two business days using the information in the form to help you resolve your issue.
Centers for Medicare and Medicaid Services (CMS)