Expiration of therapy cap

[Guest guest]

http://medicare.fcso.com/Billing_news/162161.asp

Expiration of therapy cap exceptions process

The Centers for Medicare & Medicaid Services (CMS) continues to work with

Congress on significant legislation that affects the Medicare program. We

believe this and other provisions may be extended as part of this

legislation. We encourage you to monitor Congressional activity and stay

apprised of the status of potential legislation. In the meantime, if such

legislation is enacted, CMS will notify Medicare fee-for-service claims

processing contractors to again process claims for those affected services.

Providers may choose to hold their claims in the event legislation about

this issue is enacted. However, current law mandates the following change:

The exceptions to outpatient therapy caps expire on December 31, 2009.

Outpatient therapy service providers should not submit claims with the KX

modifier for services furnished on or after January 1, 2010. The therapy

caps are determined on a calendar year basis, so all patients will begin a

new cap year on January 1, 2010. For physical therapy and speech language

pathology services combined, the limit on incurred expenses is $1,860. For

occupational therapy services, the limit is $1,860. Deductible and

coinsurance amounts applied to therapy services count toward the amount

accrued before a cap is reached.

Note that patients who have reached their limit(s) on outpatient therapy

services, other than those who reside in a Medicare-certified part of a

skilled nursing facility, may obtain medically necessary therapy services

that exceed the caps if the services are furnished and billed by the

outpatient department of a hospital. In other settings, outpatient therapy

services in excess of the caps are not covered, and the therapy provider may

charge the beneficiary for those services.

We will continue to be in communication with you should there be further

information regarding payment of claims impacted by the above guidance. In

addition, be on the alert for more information about this and other

legislative provisions which may affect you.

Kunkel MSPT

West Palm Beach