Please note that this article contains information that is only relevant to America clinics.
If you’ve read our most recent article about Medicare, then you’re definitely aware of the significant changes that were made to the therapy cap exception process. Rather, you’re aware that it was completely abolished as of January 2018. But this didn’t sit well with the outpatient rehabilitation community, and for good reason. Since then, they’ve been hoping to have the therapy cap for 2018 repealed—and their prayers have been answered.
On February 9, 2018, the United States Senate and House of Representatives passed a bill that reinstates the therapy cap exceptions for physical therapy, speech language pathology, and occupational therapy services. From here on out, if therapists who provide treatment in excess of $2,010 will need to use the KX modifier.
As a reminder, PT and SLP services combined are eligible for a maximum reimbursement of $2,010. And for OT, these services receive their own $2,010.
The KX modifier indicates that the treatment is medically necessary, despite exceeding the soft cap of $2,010. Additionally, the provider doesn’t need to issue an ABN if they’re approaching the soft cap, either.
In order for the CMS to keep a handle on this, there will be a targeted review process which investigates the legitimacy of claims exceed $3,000. This is a decrease from $3,700 last year. However, the operative word here is “targeted” as they will only be taking a closer look at the claims that fit certain criteria.
If the provider had a high percentage of claims being denied in the past, they may be subject to review. If the provider is newly enrolled in the Medicare program, they may be subject to review. And if the provider is accustomed to billing services that are infrequent amongst their peers (you guessed it), they may be subject to review.
In any case, this certainly amounts to a triumph for not only the outpatient rehabilitation community, but also the patients who rely upon their services.