Medicare Providers Wave Goodbye to Therapy Cap Exceptions in 2018

Please note that this article contains information that is only relevant to American clinics.


This year, there will be some pretty significant changes to Medicare. We’ve discussed some of these changes in a past article, but today we’ll be looking at one specific change that has the potential to completely change the way clinics provide treatment to Medicare patients. And as the title suggests, that change involves the therapy cap.


Therapy caps are not new. They’re put in place to prevent facilities and providers from taking advantage of the system by submitting endless claims and receiving endless payouts. But we all know that there are situations where even though therapy cap has been reached, the patient has not completed their course of treatment.


In the past, when situations like this arose there was a way to go above and beyond the therapy cap and continue offering treatment to the Medicare patient. In fact, there was a specific modifier that therapists could add to their CPT codes that would indicate that the therapy cap has been exceeded—this is the KX modifier—but you can’t use it anymore.


Hint: Did you know that Practice Perfect comes complete with a full list of modifiers for PTs, OTs, and SLPs? Click here to learn more about how to add modifiers to your treatment/service charges.


In 2018, there is a hard cap of $2,010 for PT services. That $2,010 is also shared with SLP services. However, there is a separate $2,010 that is available for OT services. That said, once the limit has been exceeded, the patient must assume responsibility for any further treatment. So if you notice that a patient is approaching their therapy cap, it’s a good idea to notify them that their coverage is nearly up.


Now, there is still a chance that the therapy cap exception process will be repealed, but for the time being, it’s safe to assume that Medicare providers are waving goodbye to the therapy cap exceptions in 2018.

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