Therapists providing Medicare Part B services have been on the edge of their seat these past few weeks…waiting….waiting to see how the Therapy Cap roller coaster would end.

Today a law was passed that puts an end to the cap madness. But is the ride over?

All therapists and assistants providing Part B services should familiarize themselves with the ramifications of this new law as explained here:

1- We now have a permanent fix to the Medicare Part B Therapy Cap or “hard cap”

Do we still have a Therapy Cap? Yes…of sorts. More like a hoodie…

So what’s different? We now have a permanent exceptions process, or in other terms, we have a legitimate way to exceed the “cap” or $ amount assigned yearly,  if deemed necessary. The assigned dollar amount will serve as a “marker” to trigger additional steps that need to be taken in order to receive payment.

This has been a long-time coming…20+ years! The law provides a permanent solution to the “hard cap” and prevents the ups and downs we have had over the years of watching the exceptions process expire and then be resurrected…over.and.over.again. We now have a [permanent] exceptions process in place allowing therapists to continue to exceed the cap {hoodie} limits for those services they deem medically necessary.

So it looks like KX is here to stay. We will still have an amount that is adjusted annually (PT/SLP at $2010 for 2018; OT at $2010 for 2018). Remember, the KX modifier is the therapist attestation that the services provided above the cap are medically necessary.

Medical reviews used to be at the $3,700 threshold and will now be lowered to $3,000 through 2027. Will all services over $3,000 be reviewed by CMS? No way…impossible to do in the limited budget they have. This is why CMS initiated a “targeted review process” last year. Are you a target? You are if you provide services that stand out from your peers both nationally and locally. What are your billing practices? Are you an outlier?

2- Services provided by Assistants will be paid out / reimbursed at a lower rate of 85% beginning in 2022

Thrown into the negotiating mix at the last minute was the provision to reduce payment for services provided to Part B patients when provided by a physical therapist assistant [PTA] or occupational therapy assistant [OTA]. Reimbursement for services provided by assistants would be paid at 85% of the [PFS] Physician Fee Schedule, as opposed to the current 100%.

No one saw this coming. At least not this…with this particular legislation. APTA and AOTA were not involved in this negotiation and will likely fight for a reversal or attempt to negotiate further.

Over the next few weeks we will likely receive additional information from the “fine print.” For example, is the 85% reduction for assistant-provided services in all Part B settings? Is it possible the some settings will be carved out, just like hospital outpatient therapy departments were exempt from the cap? More to come on those issues.

As far as the ruling on reimbursement for assistants…nothing with Medicare is ever final. CMS publishes a “Final Rule” every year! How is that for final?!

Hang in there, we are all in this together!

In your corner,

Dolores and The Montero Therapy Team

Providing education, training and support for SNF therapy professionals


Leave a Reply