Medicare Compliance & Reimbursement

Therapy providers continue to lobby for concrete removal of therapy caps.

Medicare is backing off its therapy cap policy that expired on Jan. 1 for Part B providers who offer outpatient therapy in the home, new guidance suggests. But the same doesn't go for rural add-on payment bonuses that expired in the New Year, also.

"Several Medicare legislative provisions affecting providers and beneficiaries recently expired, including exceptions to the outpatient therapy caps, the Medicare physician work geographic adjustment floor, add-on payments for ambulance services and home health rural services, payments for low volume hospitals, and payments for Medicare dependent hospitals," notes CMS on its website. "CMS is implementing these payment policies as required under current law."

However: "CMS is taking steps to limit the impact on Medicare beneficiaries by holding claims affected by the therapy caps exceptions process expiration for a short period of time beginning on January 1, 2018," the agency says. "Only therapy claims containing the KX modifier are being held; claims submitted with the KX modifier indicate that the cap has been met but the service meets the exception criteria for payment consideration.

Currently if claims are submitted without the KX modifier and the beneficiary has exceeded the cap the claim will be denied."

The agency continues, "CMS is not holding any other claims except those affected by the therapy caps." In other words, HHA payment rates minus the rural add-on will go forward.

Timeframe: "If legislation regarding the therapy caps is not enacted in this short period of time, then CMS will release and process the therapy claims accordingly," it says.

Meanwhile, the American Occupational Therapy Association says it is "working harder than ever to have legislation passed that would completely repeal the therapy cap. With the turn of the calendar year, the therapy cap of $2,010 went into effect, and now more than a million beneficiaries are at risk of losing access to outpatient Medicare Part B therapy services."

While waiting for Congress to act on the therapy cap issue, providers of Part B therapy should issue Advance Beneficiary Notices to patients who may exceed the cap, AOTA advises in a release. "The ABN is issued in situations where Medicare payment is expected to be denied. Because Congress didn't extend the exceptions process permitting the attachment of a KX modifier or the manual medical review process, patientsmust be notified that their therapy services maybe limited."

Reminder: The therapy cap applies to Part B outpatient therapy, including services provided in the home. It does not apply to therapy furnished under the home care benefit.