• Skip to primary navigation
  • Skip to main content
  • Skip to primary sidebar
  • Skip to footer
  • Home
  • Contact Us
  • Store
  • Checkout
  • Your Account
  • Login In
  • Sign Up

Nancy Beckley & Associates

  • Compliance
    • Knowledge Base
    • Medicare FAQ
    • Policies & Procedures
    • Compliance Outsourcing & Oversight
  • Consulting
    • Audits & Investigations
    • Mergers and Acquisitions
    • Compliance Program Development
    • Medicare Survey & Certification
    • Rehab Agencies & CORFs
      • CORFs
      • Rehab Agency
  • Training
    • Upcoming Seminars & Webinars
    • Past Seminars
    • Sample Therapy Courses and Webinars
      • ABC’s of Medicare Documentation
      • CORFs are Comprehensive Outpatient Rehabilitation Facilities
      • Medicare Compliance: Private Practice
  • About Us
    • Consultants
      • Angela Phillips, PT
      • Laura Riddell, CHC
      • Mark McDavid, OTR, RAC-CT
    • Testimonials
    • Case Studies
    • Reading Room
      • Reading Room
      • RAC Articles by Nancy Beckley
      • Books by Nancy Beckley
  • Blog

11.25.15 Compliance 2 Comments

Medicare Therapy Cap in 2016

The Medicare therapy cap in 2016 is set at $1960.  The therapy cap for physical and speech-language pathology combined is set at $1960 and there is a separate $1960 therapy cap for occupational therapy.   This represents an increase of $20 per cap over the 2015 amount of $1940.  The increment is based upon a medical economic index.  The therapy “threshold” for manual medical review (MMR) continues at $3700, where it was initiated in the 4th quarter of 2012.

Guidance in the Medicare Claims Processing Manual states (emphasis added) “It is very important to recognize that most conditions would not ordinarily result in services exceeding the cap.”  However, of note, Medicare advises beneficiaries this way regarding the therapy over the cap:

In general (when an exceptions process is in effect), if your therapist or therapy provider provides documentation to show that your services were medically reasonable and necessary and indicates this on your claim, Medicare will continue to cover its share above the $1,940 ($1,960 in 2016) therapy cap limits. Because Medicare doesn’t pay for therapy services that aren’t reasonable and necessary, your therapist or therapy provider must give you a written notice, called an “Advance Beneficiary Notice of Noncoverage” (ABN), before providing generally covered therapy services that aren’t medically reasonable and necessary for you at the time. Medicare doesn’t pay for therapy services that aren’t medically necessary. The ABN lets you choose whether or not you want the therapy services. If you choose to get the medically unnecessary services, you agree to pay for them. (source: CMS)

The Medicare Access and CHIP Reauthorization Act of 2015, (MACRA – enacted April 16, 2015) extended the therapy cap exceptions process through December 31, 2017. Changes were also made to the manual medical review process of therapy over $3700, which was to have begun in July, 2015.  The new “review” process is no longer a 100% review of all claims over $3700, but rather a review based on provider profiling and advanced data analytics. The review will focus on providers with patterns of aberrant billing practices, high claims denial percentage, those newly enrolled and other criteria.

Given that the RAC procurement process has been delayed due to bid protests beginning in 2014, there has been an updated Statement of Work (SOW) with an anticipated date of July 2016 for implementation. The therapy cap coalition group has met with CMS to discuss the implementation of the “new” manual medical review process, including discussion of selection of a CMS program integrity contractor to conduct the reviews. (no more RACs?)

Do you understand how the therapy caps exceptions process works?  Do you know how to properly provide an ABN to a beneficiary for services that are not medically necessary?  Does your documentation support therapy over the therapy cap and the $3700 threshold?

Photo: DollarPhotoClub

Thank you for Sharing!

  • Author
  • Recent Posts

Nancy

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.

Latest posts by Nancy (see all)

  • Therapy TPE Audits Continue - March 16, 2019
  • Charging for a Therapy No Show - September 28, 2018
  • Medicare Targeted Probe and Educate - September 21, 2018
Tweet
Pin
Share

Tags: $3700 threshold, CMS, Manual Medical Review, RAC, therapy cap

Reader Interactions

Comments

  1. 02.23.16 at 6:21 pmKatalin says

    thank you for this article

  2. 02.26.16 at 9:43 amNancy Beckley says

    Thank you for your kind comment.

Leave a Comment Cancel

sidebar

Blog Sidebar

Rehab Compliance Membership Program

Recent Blog Posts

Therapy TPE Audits Continue

March 16, 2019

Therapy TPE Audits Continue

Charging for a Therapy No Show

September 28, 2018

Charging for a Therapy No Show

Medicare Targeted Probe and Educate

September 21, 2018

Medicare Targeted Probe and Educate

Follow Me

TwitterFacebookLinkedin

Footer

Compliance Consulting

TwitterFacebookLinkedin

Navigation

  • Home
  • Contact Us
  • Store
  • Checkout
  • Your Account

Nancy Beckley & Associates LLC

5455 Milwaukee River Parkway
Milwaukee Wi 53209

Phone: 414-748-4376

Copyright © Nancy Beckley & Associates LLC 2010 - 2018 | All Rights Reserved