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Therapy Services


New DOTPA Reports Available

On April 28, CMS made three Developing Outpatient Therapy Payment Alternatives (DOTPA) reports available—the DOTPA Measurement Report, DOTPA Payment Alternatives Report, and DOTPA Final Report. Find these reports and additional information on the DOTPA web page.

Jimmo v. Sebelius Settlement Agreement – Program Manual Clarifications (Fact Sheet)

As explained in the previously-issued Jimmo v. Sebelius Settlement Agreement Fact Sheet (see Downloads section on the SNF PPS web page), the Centers for Medicare & Medicaid Services (CMS) is issuing revised portions of the relevant program manuals used by Medicare contractors.  For additional information, please see the  Jimmo v. Sebelius Settlement Agreement – Program Manual Clarifications (Fact Sheet) [PDF, 416KB]

Therapy Caps

Annual limitations on per beneficiary incurred expenses for outpatient therapy services under Medicare Part B are commonly referred to as “therapy caps.” All beneficiaries began a new cap year on January 1, 2015 since the therapy caps are determined on a calendar year basis. For physical therapy (PT) and speech-language pathology services (SLP) combined, the limit on incurred expenses is $1,940 in 2015. For occupational therapy (OT) services, the limit is $1,940 in 2015. Deductible and coinsurance amounts paid by the beneficiary for therapy services count toward the amount applied to the limit.

An “exceptions process” to the therapy caps is in effect through March 31, 2015. For claims furnished through March 31, 2015 that exceed the therapy caps, therapy service providers and suppliers may request an exception when one is appropriate. When the beneficiary exceeds the therapy caps and qualifies for a therapy cap exception, the provider or supplier shall add a KX modifier to the therapy Healthcare Common Procedure Coding System (HCPCS) code subject to the cap limit. By using the KX modifier, the provider is attesting that the services are reasonable and necessary and that there is documentation of medical necessity in the beneficiary’s medical record. Manual policies relevant to the exceptions process apply only when exceptions to the therapy caps are in effect.

A manual medical review process, as part of the therapy exceptions process, applies to therapy claims when a beneficiary’s incurred expenses exceed a threshold amount of $3,700 annually. Specifically, combined PT and SLP services that exceed $3,700 are subject to manual medical review, as well as OT services that exceed $3,700. A beneficiary’s incurred expenses apply towards the manual medical review thresholds in the same manner as it applies to the therapy caps. Manual medical review is in effect through March 31, 2015.

For a general overview of the medical review process, go to the Medical Review and Education website. For detailed information on therapy caps and manual medical review of therapy claims above the $3,700 threshold, visit the Medical Review and Education website’s Therapy Cap section.

Prior to October 1, 2012, the therapy caps applied to all outpatient therapy services except those furnished by hospital outpatient departments and critical access hospitals (CAHs). Between October 1, 2012 and March 31, 2015, the therapy caps apply to hospital outpatient departments. Beginning January 1, 2014, the outpatient therapy caps apply to therapy services furnished by a CAH. Therapy services furnished by a CAH are counted toward the therapy caps as if the services were paid under the Medicare Physician Fee Schedule. The amount counted toward the caps for services furnished by a CAH also reflect any applicable therapy multiple procedure payment reductions (MPPR). This provision does not change the actual method of payment for therapy services furnished by a CAH.

For information about 2014 Medicare Limits on Therapy Services, please view the Beneficiary Fact Sheet on Medicare Limits on Therapy Services. If you have questions about the Medicare Program, you should first get in touch with your Medicare Contractor. To find contact information, please use the Provider Compliance Interactive Map.


Advance Beneficiary Notice of Noncoverage Frequently Asked Questions Document Now Available

On May 1, CMS released a new Frequently Asked Questions (FAQ) document on Advance Beneficiary Notice of Noncoverage. Please view the new FAQ document, or find it in the Downloads section below.