Medicare Part B helps pay for medically necessary outpatient physical therapy, occupational therapy and speech language pathology services. Until 2018 there were annual limits on Medicare allowed payment for therapy services known as the "Therapy Cap". It was rescinded in 2018.
Although the Therapy Cap was rescinded in 2018, CMS left regulations in place requiring therapists to apply a special "KX modifier" on all claims when the Medicare allowed charges reach certain arbitrary limits known as therapy thresholds. In 2020 those limits are:
No. Since January 1, 2018 there has been no exception process and you can no longer use a KX modifier for medically necessary services that exceed the cap.
This means that CMS will deny payment of any claims that exceed the $2080 therapy threshold and Medicare beneficiaries will be responsible for payment of any claims that exceed the therapy threshold.
No. There is now a targeted review process instead.
When there is not an exceptions process in place the therapy threshold applies to all outpatient setting with the exception of hospitals.
Clinicient's EMR and medicare physical therapy billing system can help ease compliance to Medicare regulations and track the therapy threshold. Among the many features that support Medicare compliance are:
Note: The information provided herein is intended to be general in nature. It is not offered as legal or insurance related advice, and is not a complete description, or meant, or intended, to replace or be interpreted as specific, of Medicare requirements. Although every effort has been made to ensure the content herein is correct, we assume no responsibility for its accuracy. Contact Department of Health & Human Services (DHHS) Centers for Medicare and Medicaid Services (CMS) for more information.