Yes, the Therapy Cap was eliminated! After 20 years of lobbying efforts by the therapy industry and other organization representing the interests of Medicare beneficiaries, Congress passed H.R.1892, The Bipartisan Budget Act of 2018. The elimination of the therapy cap was effective January 1, 2018. Details contained in Sec. 50202 of the Act: Repeal of Medicare payment cap for therapy services; limitation to ensure appropriate therapy. See details below.
So why am I writing this Post nearly 3 years after the therapy cap was eliminated? Therapy practices are still stopping therapy at the threshold and indicating to Medicare beneficiaries that their “benefits are exhausted”. The good news is that all medically necessary therapy should be provided, as well as documentation to support the medical necessity of rehabilitation or maintenance therapy.
Outpatient therapy under Medicare Part B has a “threshold” (the amount of the old cap); services delivered beyond the threshold require a KX modifier indicating that the service meets the criteria for a payment exception. When therapy reaches a fixed amount of $3,000, it’s subject to possible targeted medical review.
Therapy Cap Eliminated: PTAs and OTAs Reimbursement Reduced (Reference)
SEC. 53107. PAYMENT FOR OUTPATIENT PHYSICAL THERAPY SERVICES AND OUTPATIENT OCCUPATIONAL THERAPY SERVICES FURNISHED BY A THERAPY ASSISTANT. ‘‘(1) IN GENERAL.—In the case of an outpatient physical therapy service or outpatient occupational therapy service furnished on or after January 1, 2022, for which payment is made under section 1848 or subsection (k), that is furnished in whole or in part by a therapy assistant (as defined by the Secretary), the amount of payment for such service shall be an amount equal to 85 percent of the amount of payment otherwise applicable for the service under this part. Nothing in the preceding sentence shall be construed to change applicable requirements with respect to such services. ‘‘(2) USE OF MODIFIER.— ‘‘(A) ESTABLISHMENT.—Not later than January 1, 2019, the Secretary shall establish a modifier to indicate (in a form and manner specified by the Secretary), in the case of an outpatient physical therapy service or outpatient occupational therapy service furnished in whole or in part by a therapy assistant (as so defined), that the service was furnished by a therapy assistant. ‘‘(B) REQUIRED USE.—Each request for payment, or bill submitted, for an outpatient physical therapy service or outpatient occupational therapy service furnished in whole or in part by a therapy assistant (as so defined) on or after January 1, 2020, shall include the modifier established under subparagraph (A) for each such service.
By the way: In order to pay for the cap outpatient therapy services performed by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) will be reimbursed at 85% of the Medicare physician fee schedule that’s not set to happen until 2022. The use of the modifier has been mandatory since 1/1/2020.