The Centers for Medicare and Medicaid Services (CMS) has announced that the therapy cap exceptions process will no longer be recognized as of today, July 1, due to the expiration of the Medicare, Medicaid, and SCHIP Extension Act of 2007.
The KX modifier, used to signal the use of the exceptions process will no longer be accepted by Medicare contractors. Speech-language pathologists should ask their clients to sign an Advance Beneficiary Notification (ABN), which advises them that absent Congressional action, effective immediately, there is a set limit on the amount of outpatient therapy service that Medicare Part B will cover. The 2008 combined therapy cap for outpatient speech-language pathology and physical therapy is $1,810, with a separate $1,810 provided for occupational therapy services. A Medicare Learning Network (MLN) Article [PDF] on the resumption of the therapy caps is available at on the CMS Web site.
Beneficiaries should also be advised that CMS has been tracking their use of outpatient therapy services since January 1, 2008. Those who have already exceeded the therapy caps and are receiving therapy services through the exceptions process will either have to seek services from a hospital outpatient department, or pay out-of-pocket for additional services. Due to consolidated billing requirements, beneficiaries receiving outpatient therapy services in a skilled nursing facility are not permitted to seek services from a hospital outpatient department and must pay out-of-pocket for therapy exceeding the cap.
Congress is expected to pass Medicare legislation which includes an extension of the therapy exceptions process after they return from recess the week of July 7th. It is unclear, whether or not the exceptions process will be made retroactive, to include those services provided between July 1 and when the President signs the bill into law. Meanwhile, CMS has indicated that all claims for services delivered on or before June 30 will be processed and paid in regular order.
ASHA will keep members abreast of any further guidance from CMS on the resumption of the therapy caps. A 2008 Medicare Therapy Cap Implementation Questions and Answers [PDF] resource and a Sample Letter to Client Announcing Therapy Cap Reinstatement [PDF] can be found on ASHA's Therapy Cap Advocacy Center. Please contact reimbursement@asha.org should you have further questions regarding the therapy caps.
Please keep watch for upcoming Action Alerts. ASHA will need your help in mounting an advocacy campaign over the next few days to press Congress to extend the therapy caps exceptions process and other Medicare issues of importance to speech-language pathologists. For questions or further information related to congressional activities on the Medicare legislation, please contact Ingrida Lusis, ASHA's Director of Federal and Political Advocacy, at ilusis@asha.org or by phone at 202-624-5951.