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CMS Final Rule and Impact to the Therapy Cap

Written by: Shawn Hewitt on Wednesday, November 8, 2017 Posted in: Outpatient Rehab


At the end of October, I blogged about a bipartisan proposal to repeal the therapy cap exception process for OT/PT/SLP.  This bipartisan effort was through the Senate Finance Committee, the House Ways and Means Committee, and the House Energy and Commerce Committee.  Since then, on November 2, 2017, the Centers for Medicare and Medicaid Services (CMS) released the final rule for services paid under the Medicare Physician Fee Schedule (MPFS).

What is important to note here under the final rule as it relates to the therapy cap, is that the therapy cap exception process for use of the KX modifier and the manual medical review process for claims over $3700 in a calendar year still expires at the end of 2017.   That means that without a change (like proposed in the previous blog) or an extension of the therapy cap exceptions process, beneficiaries become financially responsible for 100% of expenses/services that exceed the therapy cap.

There will still be a therapy cap in place but this will mean that the use of the KX modifier on these claims will have no impact as well as there will be no further medical review required. The dollar amounts for the therapy cap have increased.  In 2018, the cap threshold will be $2010 for Occupational Therapy and $2010 combined for both Physical Therapy and Speech Therapy.

One could anticipate that this will have some significant impact to the ability for some beneficiaries to continue to receive affordable care.  Make sure you have clear Advance Beneficiary Notice (ABN) process to communicate the financial responsibility for any expense/services over the new $2010 cap for the CY 2018.

Again, we will be watching closely as to what possible changes and/or extensions may occur.   Please check into our website for updates and we will communicate any impactful findings in future blog posts.

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