Alpha Lillstrom Cheng, JD, MA

THERAPY CAP

Two decades of grassroots pressure and advocacy worked—on February 9th, the permanent repeal of the therapy cap was included in the spending bill that was signed into law. Section 50202[1] of the bill repealed the long-standing therapy cap. The legislation eliminates the cap on physical therapy (PT) and speech-language pathology (SLP) services, and the separate cap on occupational therapy (OT).

THE NEW THERAPY POLICY:

Requires that the KX modifier indicating services are medically necessary must be included once PT/SLP or OT therapy spending reaches $2010 in 2018.

  1. This amount will be adjusted annually.
  2. Bills can be denied if the KX modifier is not used on claims which exceed the $2010 threshold.

Once spending reaches $3000 there is the potential for targeted medical review, triggered by factors such as:

  1. Being a new Medicare-enrolled provider,

  2. Aberrant billing as compared to peers, or

  3. Provider belongs to a practice whose partners have been flagged for aberrant billing.

  4. The $3000 amount will be adjusted annually by Medicare Economic Index (MEI) beginning in the year 2028.

New policy retroactively applied to therapy expenses incurred starting January 1, 2018.

Applies to any Medicare Part B outpatient facility: (hospital outpatient (HOPD), skilled nursing facilities (SNF) Part B, Home Health Part B, and outpatient clinics).

The budget deal also includes a pay-for that PPS does not support and worked hard to change after it was announced at the last minute—this pay-for would reduce payment for services in which a physical therapist assistant (PTA) is involved under Medicare Part B. Beginning January 1, 2022, payment for services provided by a PTA, as well as services provided by an occupational therapy assistant (OTA), would be paid at 85% of the Medicare fee schedule.

For record-keeping purposes, the bipartisan message bill to permanently repeal the arbitrary therapy cap—the Medicare Access to Rehabilitation Services Act(H.R.807/S.253)—topped out at 241 cosponsors in the House and 38 cosponsors in the Senate.

 

ADVOCACY OPPORTUNITY #1

Members of Congress really appreciate being thanked when appropriate. Use these links to see how your Representative and Senators voted on the Bipartisan Budget Act of 2018 (HR1892) which included the therapy cap repeal language:

House: http://clerk.house.gov/evs/2018/roll069.xml
Senate: https://www.senate.gov/legislative/LIS/roll_call_lists/roll_call_vote_cfm.cfm?congress=115&session=2&vote=00031

If they voted against the Bipartisan Budget Act of 2018, it might have been for a reason other than the therapy cap repeal policy, so don't be afraid to ask why they voted the way they did.
 

ADVOCACY OPPORTUNITY #2

Please let us know if your clinic employs PTAs and how your business model would be impacted by the payment differential—share their stories so that we can hit the ground running in our advocacy efforts on this front.

Keep up the good work and remember, it is an election year so all seats in the House of Representatives and 1/3 of the Senate seats will be contested.Your legislators need your vote and to hear from you. Thank you for your continued advocacy and engagement—you have just experienced how it can work.

For one-pagers and talking points for other PPS’s legislative priorities and activities,visit the Advocacy section at www.ppsapta.org