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".
In 2018, the Therapy Cap was rescinded, but CMS left regulations in place requiring therapists to apply a special "KX modifier" on all claims when the Medicare allowed charges reach certain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 2019 those limits are:
Read our recent blog for information about the CMS proposed rule for 2020.
No. As of January 1, 2018 there is 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 $2040 therapy threshold and Medicare beneficiaries will be responsible for payment of any claims that exceed the therapy threshold.
No. The manual medical review process for claims that exceed $3700 expired on December 31, 2017. There is now a targeted review process instead.
You should issue an ABN for patients reaching the cap following the ABN instructions.
When there is not an exceptions process in place the therapy threshold applies to all outpatient setting with the exception of hospitals.
Clinicient's therapy-specific EMR and billing system can help ease compliance to Medicare regulations and track the therapy threshold. Among the many features that support Medicare compliance are: