Home Advocacy Dealing With Medicare Therapy Caps: What You Need to Know

Dealing With Medicare Therapy Caps: What You Need to Know

by Michelle Mannebach
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Because Congress has not yet extended the therapy cap exceptions process for Medicare outpatient services, the hard cap of $2,010 for combined speech-language pathology and physical therapy services is in place.

Here’s what you need to know about claims for your Medicare patients who have exceeded that limit:

  • Use the –KX modifier on all claims exceeding $2,010 until Congress acts to extend the exceptions process or repeal the cap.
  • The Centers for Medicare and Medicaid services (CMS) will hold claims with the –KX modifier for anywhere from 14 to 30 days before processing, to allow Congress time to reach a solution.
  • Claims without the –KX modifier for beneficiaries that have exceeded the cap will be denied.

Providers can use an Advanced Beneficiary Notice (ABN) until the issue is resolved. An ABN informs the patient that services might not be covered and that the patient will be responsible for the charges.

  • ASHA strongly recommends use of an ABN for patients who exceed the cap and whose claims include the –KX modifier.
  • ASHA also recommends that providers collect 20 percent of the fee-for-service at the time of service and to be prepared to bill the patient for the remaining balance if Congress does not act.

ASHA staff are in daily contact with members of Congress, CMS staff and other advocates and will share any new information as quickly as possible.


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See ASHA’s resource page on the 2018 Therapy Cap Implementation for details and additional background information. Updates will be added to this page as they become available.

For questions, please contact reimbursement@asha.org.

The information and materials provided by ASHA staff are for informational and educational purposes. They do not supersede the clinical, legal or financial judgement of the practitioner, nor do they dictate a payer’s reimbursement policy. In all cases, practitioners remain responsible for their clinical practice and the use of correct coding procedures.

 

Michelle Mannebach is director, Advocacy Communications and Administration, for ASHA. MMannebach@asha.org 

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