The CMS Unveil Their Final Rules for the 2018 Medicare Physician Fee Schedule

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


Every year, the Centers for Medicare and Medicaid Services (CMS) implement changes to the Medicare Physician Fee Schedule (MPFS). These changes are intended to ensure that patients can access the healthcare services they require. They’re also implemented to ensure that therapists are receiving adequate reimbursement and can afford to continue offering their services. In this article, we’ll be reviewing the changes to the MPFS implemented by the CMS that will be affecting the 2018 calendar year.


Private practice clinics, outpatient facilities in hospitals, and skilled nursing facilities are among the practice settings to be affected by these new rules.


To start, there has been a change to the therapy cap threshold in 2018. The good news is that the dollar amount is being raised to $2,010.00. The bad news, however, is that they’re doing away with the process used to review claims exceeding $3,700.00. In fact, a recent article from Gawenda Seminars and Consulting stated that “Without a therapy caps exceptions process, the therapy caps will be applicable without any further medical review, and any use of the KX modifier on claims for these services by providers of outpatient therapy services will have no effect.”


Those of you offering orthotics at your facilities and are accustomed to billing CPT code 97760–and there’s been a slight change to this code. From 2018 onward, it is only to be used for the initial visit. To further explain, you may bill this CPT code during the patient’s initial assessment when you are determining the type of orthotic required, fitting it, training the patient on how to use it, etc. In subsequent visits, you will no longer be billing CPT code 97762, which has been deleted. It’s been replaced by CPT code 97763. And for the initial assessment for patients with prosthetics, CPT code 97761 has also been revised to specifically mention the initial encounter.


There have also been some changes to the cognitive therapy CPT codes, too. The most notable of which is the removal of CPT code 97532 (development of cognitive skills to improve attention, memory, and problem solving). This code has been replaced by CPT code 97127 (therapeutic interventions that focus on cognitive function).


In sum, there are a lot of changes to Medicare in 2018, and this article provides a mere glance of them. To learn more about how these changes will affect your private practice or outpatient facility, head over to the Gawenda Seminars or the official Medicare website.

top icon