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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."