HARD CAP ON THERAPY SERVICES NOW IN EFFECT.
You must follow ABN procedures.
As we reported in December, the allowed dollar amount for 2018 for outpatient physical therapy and speech-language pathology combined is now $2,010 with a separate $2,010 for occupational therapy.
Due to Congress’s failure to provide for an exception process (KX) a hard cap for Medicare outpatient therapy services has been instituted at the $2,010 level with some carriers publishing that services above the cap will NOT be paid.
There is no exception process (KX) or a targeted medical review threshold. (previously $3700) which basically throws us back to the hard caps put in place by the Balance Budget Act of 1997.
Under those regulations, the Part B outpatient hard cap applies to;
- Physical therapists’ (PTs’) private practices
- Offices of physicians and certain nonphysician practitioners
- Part B skilled nursing facilities
- Home health agencies (visits provided on an outpatient basis)
- Rehabilitation agencies (also known as outpatient rehabilitation facilities)
- Comprehensive outpatient rehabilitation facilities. (CORF)
- Critical access hospitals (CAHs)
It does NOT, however, apply to hospital outpatients since the failure to create or extend an exception leaves us back at the “no exceptions” rules of the Balance Budget Act of 1997.
You must now issue a valid, “mandatory” ABN to the beneficiary before providing services above the $2010, no exception cap and advise your patient that unless Congress institutes an “exception process”, they will be required to pay for all therapy rendered above the $2010 hard cap. You should inform them that they can receive additional care if it is provided at a hospital outpatient therapy department.
We have personally contacted Senator Dean Heller’s (R-NV) office to bring this situation to his attention. Both the House and Senate are back to work as of today and we look forward to a quick fix.
You may also want to contact the people’s representatives in Washington for your State.