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Therapy Cap Repeal on the Table Again

Written by: Shawn Hewitt on Tuesday, October 31, 2017 Posted in:

On Oct. 26, 2017, a bipartisan proposal was announced to repeal the infamous “therapy cap” for OT/PT/SLP. This bipartisan effort is through the Senate Finance Committee, the House Ways and Means Committee, and the House Energy and Commerce Committee.

What does this mean?

For those who manage KX modifiers and MMR, it sort of looks like a mashing up/change of the amounts and the “WHEN” to apply the KX modifier and Manual Medical Review (MMR). In the proposal, the annual therapy cap for the combined PT/SLP services as well as OT services would be eliminated (happy day!). The MMR annual amount would reduce from $3,700 to $3,000 through 2027.

So, what about the KX modifier? It looks like it does not go away completely. Even though the therapy cap is proposed to be eliminated, the need for the KX modifier would still apply to claims exceeding $3,000 in a calendar year. This would apply for the claim form for the PT/SLP combined services as well as the OT services. Any therapy (OT/PT/SLP) services under $3,000 in a calendar year will not require the KX modifier. It does not look like there will be any measures to split out PT and SLP services individually.

So, to recap the important points:

  • Therapy cap for OT and PT/SLP would be eliminated
  • MMR could change from $3,700 to $3,000 through 2027
  • $3,000 is the new value to track; KX modifiers are still required for claims exceeding $3,000 in a calendar year for OT and PT/SLP
  • OT claims for MMR and the need for KX modifiers are still looked at as separate. PT and SLP claims for MMR and KX modifiers are still looked at as combined.

“This is a major breakthrough and puts us well on our way to solving another major problem within Medicare. Like the days of SGR patches, these caps have put a strain on patients and their healthcare providers, leaving everyone wondering when they might come into effect,” said Ways and Means Committee Chairman Kevin Brady (R-TX), Ways and Means Committee Ranking Member Richard Neal (D-MA), Energy and Commerce Committee Chairman Greg Walden (R-OR), and Energy and Commerce Committee Ranking Member Frank Pallone Jr. (D-NJ). “Arbitrary caps on these important services have never made much sense as it is an important medical service that can both help patients avoid surgery or, when surgery is needed, help them recover and regain their quality of life. Now, we must shift our work to ensuring this important policy is fully offset. After 17 years of patches we can finally deliver certainty to patients who rely on these vital services.”

We will all watch closely as the proposal still needs to be accepted by the House and Senate. MACRA (H.R. 2) most recently addressed caps and MMR in 2015. A provision extended the therapy cap exceptions process until Jan. 1, 2018. Time will tell if this proposal will stick or if we will get yet another bandage in the form of an extension.

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