What are the new therapy caps for Medicare?
This change from the earlier "hard" therapy caps is the result of the Bipartisan Budget Act of 2018 (BBA of 2018) which provides for Medicare payment for outpatient therapy services including physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT) services.
How are therapy cap amounts indexed for Medicare?
Just as with the incurred expenses for the therapy cap amounts, there is one amount for PT and SLP services combined and a separate amount for OT services. This amount is indexed annually by the Medicare Economic Index (MEI). Claims for services over the KX modifier threshold amounts without the KX modifier are denied.
How much does Medicare pay for Occupational Therapy in 2018?
$2,110 for OT services. Along with this KX modifier threshold, the BBA of 2018 retains the targeted medical review (MR) process (first established through Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)), but at a lower threshold amount of $3,000.
What is the hard cap on physical therapy services?
In 2018, Medicare repealed its hard cap on physical therapy services. However, PTs must continue to track their patients’ progress toward an annual threshold. Introduced as part of the Balanced Budget Act (BBA) of 1997, the therapy cap was intended as a temporary solution to control Medicare costs.
What are the Medicare therapy Threshold limits for 2021?
For CY 2021 (and each calendar year until 2028 at which time it is indexed annually by the MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services. The targeted MR process means that not all claims exceeding the MR threshold amount are subject to review as they once were.
How is the Medicare therapy cap calculated?
Medicare allowable charges,which includes both Medicare payments to providers and beneficiary coinsurance, are counted toward the therapy cap. In outpatient settings, Medicare will pay for 80 percent of allowable charges and the beneficiary is responsible for the remaining 20 percent of the amount.
What is the therapy cap for 2020?
For CY 2020, the KX modifier threshold amounts are: (a) $2,080 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and (b) $2,080 for Occupational Therapy (OT) services.
Which of the following settings is subject to the Medicare Part B therapy cap?
The therapy cap applies to all Part B outpatient therapy settings and providers including: private practices, skilled nursing facilities, home health agencies, outpatient rehabilitation facilities, and comprehensive outpatient rehabilitation facilities.
How many therapy sessions does Medicare cover?
Although Medicare does not have a spending limit on physical therapy sessions, once the cost reaches $2,110, a person's healthcare provider will need to indicate that their care is medically necessary before Medicare will continue coverage.
How many PT sessions will Medicare pay for?
There's no limit on how much Medicare pays for your medically necessary outpatient therapy services in one calendar year.
Is there a Medicare cap?
In general, there's no upper dollar limit on Medicare benefits. As long as you're using medical services that Medicare covers—and provided that they're medically necessary—you can continue to use as many as you need, regardless of how much they cost, in any given year or over the rest of your lifetime.
Does Medicare cover therapy?
Medicare Part B covers mental health services you get as an outpatient, such as through a clinic or therapist's office. Medicare covers counseling services, including diagnostic assessments including, but not necessarily limited to: Psychiatric evaluation and diagnostic tests. Individual therapy.
What is the Medicare cap for 2022?
$2,150KX Modifier and Exceptions Process This amount is indexed annually by the Medicare Economic Index (MEI). For 2022 this KX modifier threshold amount is: $2,150 for PT and SLP services combined, and. $2,150 for OT services.
Does Medicare Part B have a cap?
The arbitrary therapy cap established for 2017 is $1980 for occupational therapy services and a separate therapy cap of $1980 for physical therapy and speech-language pathology services combined. This policy puts the government between the patient and the health care provider.
What will be the Medicare premium for 2021?
The Centers for Medicare & Medicaid Services (CMS) has announced that the standard monthly Part B premium will be $148.50 in 2021, an increase of $3.90 from $144.60 in 2020.
What does KX modifier mean?
The KX modifier, described in subsection D., is added to claim lines to indicate that the clinician attests that services at and above the therapy caps are medically necessary and justification is documented in the medical record.
What is the Medicare cap for physical therapy?
This is a huge win for Medicare beneficiaries. The 2018 therapy cap for physical therapy is $2,010. Physical, occupational and speech therapy services can be rendered above this threshold ...
When will CMS release KX modifier?
Per the CMS website, " Starting January 25, 2018, CMS will immediately release for processing held therapy claims with the KX modifier with dates of receipt beginning from January 1-10, 2018.
Does Medicare pay claims above $2,010?
Medicare will not pay claims above the $2,010 threshold regardless of whether a KX modifier has been appended. However, because this legislation is still in “limbo” it is important that you currently do not bill the patient for this amount as there is a good chance that Medicare will end up paying these claims.
Is there a hard cap on KX?
Any claims that are above the cap and are not submitted with a KX modifier will be denied by CMS. In summary, there is still a hard cap on therapy with no exceptions process and Medicare will hold claims containing a KX until a decision is made in Washington, DC. Stay tuned.
When is the KX modifier retroactive?
The therapy cap fix is retroactive to January 1, 2018 and providers should re-submit any claims that have been denied due to the cap limit.
Is the home health insurance cut for 2020?
Starting in 2020, the unit of payment will change 60 days to 30-day units and the market basket rate will be set at 1.5%.
Is Medicare Part D coverage gap closed?
Though there is beneficial news for seniors, in that the coverage gap in Medicare Part D plans (“ the donut hole”) is partially closed by the budget deal. Beneficiaries will only be responsible for contributing 25% of prescription costs.
When will Medicare stop cap?
This change is effective for all claims occurring on or after January 1, 2018.
When will physical therapy assistants get reimbursed?
The new law also changes reimbursement for services provided by physical therapist assistants and occupational therapy assistants. Starting January 1, 2022, services furnished by PTAs and OTAs will be reimbursed at 85% of the usual rate.
How much does the KX modifier apply to Medicare?
Therapists must still track total claim amounts for Medicare beneficiaries and apply the KX modifier to claims exceeding the $2,010 threshold . Additionally, the targeted review process will now apply to therapy claims exceeding $3,000 for each individual patient—instead of $3,700, as was the case in previous years.
When does Medicare start processing claims?
Then, as of January 25, CMS began processing the held claims it received between January 1 and January 10. As for any claims received after January 10, CMS began processing these as of January 31. Going forward, Medicare is processing any claims received after January 10 on a 20-day rolling hold.
When does CMS start holding KX?
On January 1, 2018, with no legislation to ensure the continuation of the exceptions process, CMS began holding any claims with a “date of receipt” occurring between January 1 and January 10 that contained the KX modifier.
Is there a hard cap on Medicare?
Thus, for the first time since the therapy cap was introduced, a hard cap went into effect for 2018, putting immense pressure on therapists who treat Medicare patients. Fortunately, the year is still young enough that most patients haven’t met the $2,010 cap. However, if Congress doesn’t act fast, there’s going to be a lot ...
Spotlight
The Therapy Services webpage is being updated, in a new section on the landing page called “Implementation of the Bipartisan Budget Act of 2018”, to: (a) Reflect the KX modifier threshold amounts for CY 2021, (b) Add more information about implementing Section 53107 of the BBA of 2018, and (c) Note that the Beneficiary Fact Sheet has been updated.
Implementation of the Bipartisan Budget Act of 2018
This section was last revised in March 2021 to reflect the CY 2021 KX modifier thresholds. On February 9, 2018, the Bipartisan Budget Act of 2018 (BBA of 2018) (Public Law 115-123) was signed into law.
Other
On August 16, 2018, CMS issued a new Advance Beneficiary Notice of Noncoverage (ABN) Frequently Asked Questions (FAQ) document to reflect the changes of the Bipartisan Budget Act of 2018. Please find the document in the below Downloads section titled: “August 2018 ABN FAQs”.
What is the KX modifier threshold for BBA?
Along with the KX modifier threshold, the BBA of 2018 retains the targeted medical review process that was established in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). For 2018 through 2028, the targeted medical review threshold is $3,000 for PT and SLP services, and $3,000 for OT services. (After 2028, the threshold will be indexed annually by the MEI.) As the name implies, targeted medical review means that not all claims exceeding the therapy threshold amount are subject to review.
Do you need to submit special documentation along with the KX modifier threshold?
You do not need to submit special documentation along with the KX modifier threshold. You are responsible for consulting guidance in the Medicare manuals and professional literature to determine if the beneficiary qualifies for the exception.
What is the Medicare therapy cap?
However, Congress repealed the Medicare therapy cap in 2018, allowing more Medicare beneficiaries to be able to afford physical therapy and other services.
Why do Medicare patients get physical therapy?
Medicare patients typically receive physical therapy and other services to recover from injuries, medical procedures, or health emergencies like a stroke. It may also be used to help patients cope with disabilities or chronic conditions such as Parkinson's disease. Orthopedic issues are another reason why many Medicare patients receive physical ...
What is an ABN for a therapist?
If your therapist plans to provide you with services that aren't medically necessary , he or she must give you an Advance Beneficiary Notice of Noncoverage (ABN) first. The notice allows you to choose whether or not you want the therapy services, with the understanding that you agree to pay for medically unnecessary services. This includes services that would generally be covered under Medicare but are not necessary or reasonable for you at the time.
Is there a cap on physical therapy for Medicare?
However, Congress repealed the Medicare therapy cap in 2018, allowing more Medicare beneficiaries to be able to afford physical therapy and other services. While the current Medicare law has removed the Medicare therapy cap for medically necessary outpatient therapy services, there are a few things to note.
Does Medicare cover physical therapy for osteoarthritis?
For conditions such as osteoarthritis, physical therapy can reduce pain and stiffness while improving mobility. The use of physical therapy for osteoarthritis can also delay or eliminate the need for knee replacement surgery. Original Medicare will cover 80 percent of the Medicare-approved amount for outpatient therapy services, ...
