Therapy Services

Spotlight

The Therapy Services webpage is being updated, in a new section on the landing page called “Implementation of the Bipartisan Budget Act of 2018”, to: (a) Reflect the KX modifier threshold amounts for CY 2021, (b) Add more information about implementing Section 53107 of the BBA of 2018, and (c) Note that the Beneficiary Fact Sheet has been updated.

Implementation of the Bipartisan Budget Act of 2018

This section was last revised in March 2021 to reflect the CY 2021 KX modifier thresholds. On February 9, 2018, the Bipartisan Budget Act of 2018 (BBA of 2018) (Public Law 115-123) was signed into law. This law included two provisions related to Medicare payment for outpatient therapy services including physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT) services:

Through section 50202 of the BBA of 2018, the law preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record. Just as with the incurred expenses for the therapy cap amounts, there is one amount for PT and SLP services combined and a separate amount for OT services. This amount is indexed annually by the Medicare Economic Index (MEI).  Claims for services over the KX modifier threshold amounts without the KX modifier are denied.  For CY 2021 this KX modifier threshold amount is:

  • $2,110 for PT and SLP services combined, and
  • $2,110 for OT services.

Along with this KX modifier threshold, the BBA of 2018 retains the targeted medical review (MR) process (first established through Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)), but at a lower threshold amount of $3,000. For CY 2021 (and each calendar year until 2028 at which time it is indexed annually by the MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services. The targeted MR process means that not all claims exceeding the MR threshold amount are subject to review as they once were. For a general overview of the MR process, go to the Medical Review and Education website.  Lastly, Section 50202 of the BBA of 2018 did not change the provider liability procedures which first became effective January 1, 2013 (with passage of The American Taxpayer Relief Act of 2012 (ATRA)) and continues to provide limitation of liability protections to beneficiaries receiving outpatient therapy services when services are denied for certain reasons, including failure to include a necessary KX modifier. Please refer to the document titled  “August 2018 ABN FAQs (PDF)” posted in the Downloads section below. 

Section 53107 of the BBA of 2018 additionally requires CMS, using a new modifier, to make payment at a reduced rate for PT and OT services that are furnished in whole or in part by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs).  Payment for these services is at 85 percent of the otherwise applicable Physician Fee Schedule payment amount/rate for the service, effective January 1, 2022. The BBA of 2018 established interim dates to implement the payment reduction via notice and comment rulemaking: (a) establish a new modifier to identify services furnished in whole or in part by a PTA or OTA by January 1, 2019 and (b) require the modifier on claims beginning January 1, 2020.  For CY 2019, CMS created two payment modifiers as follows:

  • CQ modifier:  PT services furnished in whole or in part by PTAs and
  • CO modifier: OT services furnished in whole or in part by OTAs. 

For CY 2020, CMS established a de minimis standard for such services – meaning that portions of a service furnished by the PTA/OTA independent of the physical therapist/ occupational therapist, as applicable, that do not exceed 10 percent of the total service are not subject to the payment reduction; while portions of a service furnished by the PTA/OTA independent of the therapist that exceed 10 percent of the total service must be reported with the CQ/CO modifier, alongside of the corresponding GP/GO therapy modifier.  Portions of services provided by the PTA/OTA together with the physical therapist/occupational therapist are counted as services provided by physical and occupational therapist. 

For more information for beneficiaries about Outpatient Therapy Services, including the repeal of the therapy caps under the BBA of 2018, 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.

For more information about other outpatient therapy payment policies, please see:

For applicable coverage policies for therapy services, please refer to the Medicare Benefit Policy Manual:

Other

A New Advance Beneficiary Notice of Noncoverage (ABN) Frequently Asked Questions (FAQs) Document Is Now Available

On August 16, 2018, CMS issued a new Advance Beneficiary Notice of Noncoverage (ABN) Frequently Asked Questions (FAQ) document to reflect the changes of the Bipartisan Budget Act of 2018. Please find the document in the below Downloads section titled: “August 2018 ABN FAQs”.

 

Page Last Modified:
03/31/2021 03:04 PM