The fee schedules for 2019 received a 0.1 percent increase and have been in place since Jan. 1, 2019. The Bipartisan Budget Act of 2018 eliminated the caps for therapy services but the KX modifiers are still required on claims to provide attestation of medical necessity. An automatic targeted medical review process will be in place for services over the threshold for 2019. Physical therapy and speech language pathology services over $2,040 should have the KX modifier. Occupational therapy services over $2,040 should also have the KX modifier.
Documentation should always include physician certifications and recertifications. Days and minutes of therapy should be provided according to the signed and dated plan. Patient documentation should include the medical reasons for therapy including diagnosis codes and comorbidities that support the need for skilled therapy services.
Services over the $3,000 threshold will be subject to a targeted medical review for physical therapy, speech language pathology and occupational therapy. Per the Centers for Medicare & Medicaid Services, factors that may lead to a further review include:
- High denial rates
- Aberrant patterns of billing in comparison to peers
- Newly enrolled providers
- Services that target specific types of medical conditions
The Multiple Procedure Payment Reduction remains in place. There is a reduction in payment for certain services that are performed during a single patient encounter. Typically the highest value procedure is paid at 100 percent of the fees schedule and the second procedure will be reimbursed at 50 percent of the fee schedule.
Other 2019 changes include:
- Medicare Part A coinsurance is $170.50 for days 21 through 100
- Part B deductible is $185
For additional information, contact Joan McCarthy, RSM health care consultant, at +1 312 634 3479.
