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2015 Therapy Cap Values

November 26, 2014 1 Comment

January 1 on blackboard banner

CMS has announced the 2015 Therapy Cap values for 2015 for physical therapy and speech-language pathology combined and occupational therapy.    The therapy caps were initiated under the Balanced Budget Act of 1997 (P.L. 105-33, Section 4541(c)) to implement a per beneficiary annual cap (financial limitation) on the amount of therapy services under Medicare Part B.  The original therapy caps were established at $1500 of PT/ST and OT, although not permanently in place until 2006 due to the moratorium on therapy cap implementation that was in place.

2015 Therapy Cap Values

The 2015 therapy cap value has been bumped by $20 for a beneficiary cap of $1940 for the coming year.  The increase over the 2014 therapy cap amount is calculated annually via the Medical Economic Index.  While the therapy cap values have increased the threshold of $3700 for manual medical review has not changed.

Some important facts to keep in mind for therapy and billing staff alike:

  • The therapy cap is a calendar year beneficiary limit for medically necessary therapy services
  • Services that are not medically necessary, either before or after the cap, may not be billed to Medicare
  • For non-medically necessary services or non-covered services the beneficiary may sign a waiver of liability with a properly executed Advanced Beneficiary Notice of Non-Coverage (ABN)
  • The KX modifier must be appended to all medically necessary services over the cap
  • The $3700 threshold in not another cap, but rather a point of “manual medical review” of claims over the threshold to ensure medical necessity of services

Are you prepared for the 2015 therapy cap?  Do you have current beneficiaries that are approaching the cap this year, and you plan on stopping therapy until 2015?  (If so you may want to read this post.)

Photo Credit:Dollar Photo Club: marinini

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Nancy Beckley

Nancy J. Beckley MS, MBA, CHC: President-Nancy Beckley & Associates LLC. Compliance outsourcing, risk assessment, compliance plans, compliance training, auditing, due diligence, investigation support for therapy providers.

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