Earlier this week, CMS clarified that outpatient rehabilitation therapy benefits paid while receiving care at a critical access hospital will apply toward the therapy cap; however, the CAH itself is not required to utilize the therapy cap exception (KX modifier) or manual medical review process. As it pertains to the benefits paid, the physician fee schedule will be used to track the amount accumulated toward the cap, not the cost-based reimbursement schedule under which CAHs are paid. We are seeking clarification for when CMS’s systems will be ready to process this information correctly.
Example: If a patient received outpatient services at a CAH in 2013 and accumulated $1900 in expenses, if the patient receives Medicare Part B therapy services at any another location but a CAH (private practice, hospital based outpatient, SNF, etc), those locations would be subject to the therapy cap exception process and have to apply the KX modifier on their claims. If the patient continued to receive therapy at the CAH, the CAH would not need the KX or be subject to manual medical review once $3700 was reached.