Senator Ben Cardin (MD) has proposed repeal legislation, the Medicare Access to Rehabilitation Services Act, which would repeal the annual cap on Medicare rehab services. Margaret Danilovich, physical therapist and public health researcher at Northwestern University, argues that the therapy cap is costly in the long run to patients’ health.
Full Answer
What is the Medicare therapy cap?
Prior to 2018, Medicare enforced a ‘therapy cap’ for any beneficiary receiving physical therapy (PT), occupational therapy (OT), or speech-language pathology (SLP) services. Ultimately, a patient was only able to receive treatment until a set amount, after which the services would not be eligible for reimbursement by Medicare.
What are the Medicare physical therapy caps for 2022?
Effective January 1, 2022, the current Medicare physical therapy caps are: $2,150 for combined physical therapy and speech-language pathology services. $2,150 for occupational therapy services.
What is the Medicare therapy threshold or kx modifier?
The Bipartisan Budget Act of 2018 repealed the therapy cap, and instead replaced it with the Medicare therapy threshold or KX modifier threshold. Unlike the previous cap, the therapy threshold is not designed to be a hard stop for services.
What is targeted medical review for physical therapy?
It serves as a type of checks and balances for providers who exceed the Medicare physical therapy cap. Between 2018 and 2028, the targeted medical review threshold is $3,000 for combined PT and SLP services and $3,000 for OT services. Services above $3,000 may be subject to targeted medical review.
What does the repeal of the OT cap for Medicare B mean?
Section 50202 of the Act, “Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy,” states that the repeal of the therapy caps is retroactive.[1] This means that therapy caps have been removed for all physical therapy, occupational therapy, and speech-language pathology services ...
What is the Medicare threshold for physical therapy in 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.
What does Medicare cap mean?
A CAP is a narrative of steps taken to identify the most cost effective actions that can be implemented to correct errors causes. Following each measurement cycle, States included in the measurement are required to develop and submit a separate Medicaid and CHIP CAP designed to reduce improper payments in each program.
What is the therapy cap for 2021?
Beginning January 1, 2021 there will be a cap of $2110.00 per year for Physical Therapy and Speech-language pathology together. A separate cap of $2110.00 per year is allowable for Occupational Therapy Services. Medicare pays 80% of allowable charges.
How many PT sessions will Medicare pay for?
Medicare Coverage The good news is there's no limit on the number of physical therapy treatments within one calendar year as long as your physician or physical therapist can certify that treatment is medically necessary.
How much does Medicare reimburse for physical therapy?
However, in 2018, the therapy cap was removed. Original Medicare covers outpatient therapy at 80% of the Medicare-approved amount. When you receive services from a participating provider, you pay a 20% coinsurance after you meet your Part B deductible ($233 in 2022).
What is the purpose of a corrective action plan CAP )?
Definition(s): Corrective actions for an issuer for removing or reducing deficiencies or risks identified by the Assessor during the assessment of issuer operations. The plan identifies actions that need to be performed in order to obtain or sustain authorization.
What is a cap corrective action plan?
• A corrective action plan (CAP) is a step by step plan of action. that is developed to achieve targeted outcomes for resolution. of identified errors in an effort to: - Identify the most cost-effective actions that can be. implemented to correct error causes.
Does Medicare have a 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.
Can physical therapist bill Medicare?
Physical therapy billing guidelines for Medicare and Medicaid services include a section about how much time you must spend with a patient for it to be “bill-worthy.” Medicare physical therapy billing works in increments of 15.
Does Medicare pay for physical therapy at home?
Medicare Part B medical insurance will cover at home physical therapy from certain providers including private practice therapists and certain home health care providers. If you qualify, your costs are $0 for home health physical therapy services.
What does the KX modifier mean?
The KX modifier is a Medicare-specific modifier that indicates a beneficiary has gone above their therapy threshold amount.
What therapy types are affected?
The repeal affects three therapy types: physical therapy (PT), occupational therapy (OT) and speech-language therapy (SLP).
Repealing therapy caps is significant
The caps had previously been in place for 20 years, with caps for physical and speech therapies set at $2,010, combined, and $2,010 for occupational therapy—per patient per year.
Potential problems
While many organizations and therapy patients are celebrating the good news, there is some potential bad news on the therapy side.
What is the Medicare Part B cap?
Medicare Part B covers medically necessary physical therapy and speech language pathology. For two decades, there has been a cap on the amount covered for these services under Medicare. For 2018, the cap was to be $2,010 for physical therapy and speech language pathology services combined and $2,010 for occupational therapy services.
Can you get physical therapy with Medicare?
Effective January 7, 2014, Medicare beneficiaries can no longer be denied coverage for physical, occupational, or speech therapy simply due to lack of improvement – a decision that greatly benefits those with Parkinson’s, Alzheimer’s, and other chronic conditions.
What happens if an older person falls in January?
This also means that if an older person falls in January, they may use up all their therapy benefits for the entire year. If another health conditions arises later in the year, that individual could be left with no coverage for outpatient rehabilitation services.
What is a physical therapist?
Physical therapists are experts in evaluating and treating these issues, yet older adults with these multiple chronic diseases and movement problems reach their therapy cap quickly, limiting their access to necessary care.
Why is physical therapy important?
Physical therapist care has routinely shown to improve health outcomes and decrease health care costs. Eliminating the cap and investing in greater amounts of physical therapist services will put our society on a healthier path to a more cost-effective health care system. Aging is inevitable and most, if not all people will need a physical ...
How many therapist sessions are needed to prevent falls?
Falls are the number one cause of injuries among older Americans. The solution to prevent and treat falls is physical therapist intervention. The 16 yearly therapy sessions under the cap is often an insufficient amount to fully recover from a fall or prevent deadly falls from occurring.
What percentage of older adults have chronic diseases?
Sixty nine percent of older adults manage at least two chronic diseases that are often associated with difficulties walking, moving in and out of a chair, and accessing the community for necessary tasks like grocery shopping and going to the doctor.
Why do older people need physical therapy?
One of the reasons that older adults seek a physical therapist is due to age-related progressive conditions like Alzheimer’s or Parkinson’s disease. Further, certain medical conditions like stroke and frailty occur with greater frequency as one ages.
How much will Medicare increase without a cap?
Without a therapy cap, the amount of therapy services billed to Medicare will likely increase as older adults are no longer limited to $1,980 per year. However, increased spending in preventive and comprehensive therapy services is ...
What is the repeal of the Medicare outpatient cap?
The Act repealed the Medicare outpatient therapy caps, which functioned as a barrier to care for those receiving outpatient therapy services. Section 50202 of the Act, “Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy,” states that the repeal of the therapy caps is retroactive. [1] This means that therapy caps have been removed for all physical therapy, occupational therapy, and speech-language pathology services provided “after December 31, 2017.”[2]
Can Medicare patients continue therapy?
Medicare beneficiaries who are told they cannot continue therapy because they have reached a therapy cap should direct their physicians and therapists, or any Medicare contractors reviewing their claim, to the repeal language in the Bipartisan Budget Act of 2018 and the MLN Connects newsletter.
Can Medicare beneficiaries continue outpatient therapy?
Sebelius, No. 11-cv-17 (D. VT), Medicare beneficiaries should now be able to continue receiving outpatient therapy to improve or maintain their current conditions, or to slow or prevent the further deterioration of their conditions, without having to overcome arbitrary payment caps as barriers to care. To read the Bipartisan Budget Act of 2018, ...
Is the Medicare reimbursement cap retroactive?
Section 50202 of the Act, “Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy,” states that the repeal of the therapy caps is retroactive. [1] .