United States

Senior Living Health Care Connection: Part B therapy alert


Congress failed to act on the therapy cap exception process that expired Dec. 31, 2017. As of Jan. 1, 2018, the exception process that allowed the use of the KX modifier to establish medical necessity above the therapy cap can no longer be used. Therapy caps for calendar year 2018 include the following: $2,010 for physical therapy and speech-language pathology combined, and $2,010 for occupational therapy. As of this writing, Congress hasn’t acted but providers expect that there will be further guidance when Congress returns on Jan. 19. We will keep you posted.

Part B therapy providers should monitor the amount of therapy furnished beginning with services on Jan. 1, 2018. This applies to all therapy services regardless of whether the services are in the episode of care starting in 2017. Each therapy is counted separately so if a beneficiary receives $2,010 in physical therapy services then he or she would still be eligible to receive occupational therapy services up to the cap, but not for physical or speech therapies, as that cap has been reached. If the caps are exceeded, beneficiaries can still receive medically necessary services, but the beneficiary would be responsible for payment of services above the cap.

Per Centers for Medicare and Medicaid Services, providers must issue a valid, mandatory Advanced Beneficiary Notice (ABN) to the beneficiary before providing services above the cap. This ABN advises the beneficiary that Medicare may not make payment, and the beneficiary can choose whether or not to get the services and accept financial responsibility. If the ABN is not issued, the provider is liable for the charges. Most therapy is billed the month after the services are provided so therapy provided in January will not, in most cases, be billed until February. Providers should consider delaying their billing until there is further guidance regarding the therapy caps.

For more information, contact Joan McCarthy at +1 312 634 3479.

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