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OP Therapy Cap: Congress Votes on Full Repeal

Written by: Shawn Hewitt on Monday, February 12, 2018 Posted in:

therapy cap repeal 2018We have been waiting to see if, how, and when there would be repeal or replace legislation that would impact the recent therapy payment cap exceptions expiration that went into effect on January 1, 2018.  On February 9, 2018, President Trump signed a spending bill that included a number of key provisions for health care programs, including a repeal of the payment cap for therapy services.  According to Healthcare IT News, “[The] Senate passed the spending bill around 1:45 a.m. with a 71-28 vote, while the House pushed through the legislation at about 5:30 this morning with a 240-186 vote. The President tweeted that he signed the bill into law at 8:40 this morning.”

Here are some of the key provisions affecting rehab therapists that are known as of 2/12/2018:

  • The hard therapy cap of $2,010 for occupational therapy and physical therapy/speech language pathology combined has been eliminated. That means Congress will not need to vote on exceptions to a cap each year.
  • Manual medical review (MMR), will have a threshold of $3,000 through 2027.  This changes from the previous $3,700 amount.  The new law also specifies that claims will no longer “automatically” be subjected to a targeted medical review.  However, for claims that exceed $3,000, a percentage of providers who meet certain criteria may be targeted for medical review.
  • KX modifiers will still be utilized.  The KX modifier is required for claims that go above a $2,010 amount for the 2018 calendar year. This will count for $2010 for occupational therapy and $2010 for physical therapy/speech language pathology combined. The hard cap has been eliminated but the purpose of the KX modifier for claims over the $2010 amount is for attestation that the therapy services provided are medically necessary.  Claims above the $2010 without the KX modifier will be denied from the MAC’s.
  • These changes are for all settings that provide outpatient therapy services.  (including Hospital Outpatient)
  • Starting in 2022, occupational therapy assistant (OTA) and physical therapy assistant (PTA) services will see a reduced payment for outpatient therapy paid under the Medicare Physician Fee Schedule. There will be a new modifier that will specify that submitted services were provided by an OTA and PTA.
  • Starting in 2020, we will see some changes to the way home health payments will be structured under Medicare.

The repeal of the therapy cap means that Medicare beneficiaries now have one less hurdle to contend with as they access therapy services.

We will learn more in the coming days as we gain better understanding of all the specific language passed in the bill.  Mediware is committed to provide you with relevant information to make sure you are set up for success in the care and treatment of your patients.

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