by Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
May 4th, 2017
The annual combined therapy cap is per beneficiary each calendar year. For 2017, this includes Medicare Part B outpatient therapy cap for Occupational Therapy (OT) $1,980, Physical Therapy (PT) and Speech-Language Pathology Services (SLP) $1,980.
In addition there is an exception process, if the therapy services are higher than the limited amounts, the beneficiary may qualify exception to the therapy cap. Per CMS, Medicare will pay above the $1980 therapy limits under the following conditions:
- Therapist or therapy provider provides documentation to show that services were medically reasonable and necessary.
- Therapist or therapy provider that services were medically reasonable and necessary on a claim.
If the beneficiary's services exceed the $3,700 threshold, there will be a medical claim review done by Medicare Administrator Contractors (MACs). The exception to this would be Critical Access Hospitals (CAHs) are excluded from review as well as all claims submitted with a KX modifier, stating specific required documentation is on file and it is documented as medically necessary.
The therapy cap applies to all Part B providers and outpatient therapy services including:
Therapists’ private practices
Offices of physicians and certain nonphysician practitioners
Part B skilled nursing facilities
Home health agencies (Type of Bill (TOB) 34X)
Rehabilitation agencies (also known as Outpatient Rehabilitation Facilities-ORFs)
Comprehensive Outpatient Rehabilitation Facilities (CORFs)
Hospital outpatient departments (HOPDs)
Critical Access Hospitals (CAHs) (TOB 85X) - (2014)
In addition, the therapy cap will apply to outpatient hospitals as detected by:
Type of Bill 12X, 13X or 085X
Revenue code 042X, 043X, or 044X
Modifier GN, GO, or GP; and
Dates of service on or after January 1, 2014
Be sure to utilize an "Advance Beneficiary Notice of Noncoverage" (ABN), if the therapy cap has been reached and the services are considered not reasonable and necessary.