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Keep On Keeping On

Published on 

Monday, January 27, 2014

 | AL Medicaid 
 | Outpatient Services 

Every year, there are a number of Medicare provisions that expire on a particular date. For the requirements of these provisions to continue past the expiration date, Congress must take action through a new law. Such was the case for several rehabilitative therapy provisions set to expire at the end of 2013. The Pathway for SGR Reform Act of 2013, signed into law on December 26, 2013 extended the following provisions related to payments for Medicare outpatient therapy services through March 31, 2014.

Application of therapy caps and therapy threshold to therapy services furnished in a hospital outpatient department -

Therapy caps are a financial limitation on the amount Medicare allows for outpatient therapy services for a single Medicare patient in a given calendar year. The therapy cap amount for each patient starts over each January 1st. For 2014, the therapy cap is $1,920 for physical therapy (PT) and speech language pathology (SLP) services combined; and a separate $1,920 for occupational therapy (OT) services.

Exceptions process for outpatient therapy caps -

When providers of therapy services furnish medically necessary therapy services beyond the therapy cap, they may request an exception by appending the KX modifier to the appropriate therapy services on the claim. Additional information about the exception process for therapy services may be found in the http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c05.pdf">Medicare Claims Processing Manual, Pub.100-04, Chapter 5, Section 10.3.

Manual medical review of outpatient therapy services exceeding the threshold amount -

Medicare mandates that a Medicare contractor perform a manual medical review of therapy services exceeding a $3,700 threshold for PT and SLP services combined and a $3,700 threshold for OT services. Currently this review function is being handled by Medicare Recovery Auditor contractors.

Critical Access Hospitals will also want to study MLN Matters Article MM8426 concerning the application of therapy caps, the exceptions process, and manual medical review to outpatient therapy services provided in the CAH setting.

So we are all set for … well, three months. If this year follows the pattern of previous years, another law will likely extend these provisions through the remainder of 2014. But, we will just have to wait and see.

 

Article Author: Debbie Rubio, BS MT (ASCP)
Debbie Rubio, BS MT (ASCP), was the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.