Outpatient Medicare Therapy Benefits: what do therapy caps mean to you?
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  • As part of The Middle Class Tax Relief and Job Creation Act of 2012, CMS implemented therapy caps for hospital outpatient departments. HHH has received many inquiries about what the therapy caps mean for you, as an individual. The therapy caps refer specifically to physical therapy, occupational therapy and speech language therapy services.
    This is an attempt to explain what therapy caps and thresholds mean.

    Therapy Cap Dollar Amounts

    • The therapy cap dollar amount for calendar year 2013 is $1900.00 for physical therapy (PT) and speech therapy (SLP) combined and a separate $1900.00 for occupational therapy (OT).
    • The amounts contributing to the caps are based on the Medicare Fee payment and tallied for each Procedure Code (CPT) that the Hospital submits charges on.
    • Once a patient meets the therapy cap dollar amount for OT or PT/SLP combined, a KX modifier must be appended to the CPT codes on the claims the Hospital submits for payment. The KX modifier allows payment above and beyond the maximum therapy cap dollar amount of $1900.00
    • By appending the KX modifier to the code; the therapist is attesting to the fact that the therapy is still medically necessary and that the patient will benefit from the therapy.

    Providing the therapist considers that therapy is medically necessary the KX modifier is appended to the claims until a threshold of $3700.00 is reached.

    Therapy Thresholds

    • Once a patient exceeds $3700.00 for OT or $3700.00 for PT/SLP a manual medical review is mandated.
    • The manual medical review is a request to receive an exception to continue treatment beyond the $3700.00 thresholds.
    • The request for further therapy must clearly show the need for continued treatment. The reasons for this treatment must be clear, reasonable and prove the necessity of further treatment continuation.

    At any time the Hospital may be requested to send the medical documentation showing that all services rendered were considered medically necessary.
    If you have any questions about your Therapy Cap or Threshold ask your therapist.

    Definition of Medically Necessary:

    There needs to be an expectation that the patient’s condition will improve significantly in a reasonable (and generally predictable) period of time.

    Patients have a responsibility to actively participate in a home program while in therapy to maximize achievement of goals/gains and to continue their recommended program after discharge to continue to progress/maintain their status when a skilled therapist is no longer medically necessary.
    - Bruce Marshal, DDS
    - Director, Medical and Professional Services

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