Update to Medicare Therapy Cap and Threshold 2013
January 1, 2013 through March 31, 2013
-Annual per beneficiary therapy cap amount is $1900 for physical therapy and speech language pathology services combined and there is a separate $1900 amount allotted for occupational therapy services.
-Providers may utilize the automatic process for exception for any diagnosis for which they can justify se…rvices exceeding the cap. Therapists may request an automatic exception for claims that are between $1900 and $3700 in expenditures. When the beneficiary qualifies for a therapy cap exception, the provider shall add a KX modifier to the therapy procedure code subject to the cap limits.
-Manual Medical reviews-completed on every claim at and after the beneficiary’s services exceed $3700.00
April 1, 2013 through December 31, 2013
-Annual per beneficiary therapy cap amount is $1900 for physical therapy and speech language pathology services combined and there is a separate $1900 amount allotted for occupational therapy services.
-Providers may utilize the automatic process for exception for any diagnosis for which they can justify services exceeding the cap. Therapists may request an automatic exception for claims that are between $1900 and $3700 in expenditures. When the beneficiary qualifies for a therapy cap exception, the provider shall add a KX modifier to the therapy procedure code subject to the cap limits.
-Recovery Auditors will conduct prepayment manual medical review in 11 demonstration states:
CA, FL, IL, LA, MI, MO, NC, NY, TX, OH, PA
-CMS will grant an exception to all claims with a KX modifier at and after the beneficiary’s services exceed $3700.00 and Recovery Auditors will conduct post payment review on all claims in the remaining states.
In the non-Demonstration states, the Recovery auditors will conduct immediate post-payment review. All claims will continue to go the MAC and once received the MAC will pay claim. The Recovery Auditor will then issue an Additional Documentation Request letter to the provider. The Recovery Auditor will complete manual medical review within 10 business days of receiving the additional documentation and will notify the MAC of the payment decision. If services are denied, the MAC will retract the payment.