The Medicare Physical Therapy Cap, an essential element of the Balanced Budget Act (BBA) 1997, was originally designed as a temporary cost-control measure. Despite a strong push for its repeal, Congress continued to renew it each year until 2018. This year, the cap was replaced with a soft cap, otherwise known as an annual threshold amount.
What is the Physical Therapy Medicare Cap for 2024?
The therapy threshold for Calendar Year (CY) 2024 is $2,330 for physical therapy and speech-language pathology services combined and $2,330 for occupational therapy services. A $100 increase from last year’s amount for both. After passing the cap, the KX modifier must be affixed to all claims for medically necessary services that exceed this threshold.
Services That Count Towards the Therapy Threshold
The Physical Therapy Medicare Cap for 2024 applies to all Part B outpatient therapy services furnished in various locations. It is crucial to note that therapy services received due to multiple diagnoses over the benefit period all count towards the patient's threshold. The threshold, however, should not deter Medicare patients from receiving medically necessary care.
How to Calculate a Patient's Progress Towards the Therapy Threshold
Every time a new patient seeks treatment, it's essential to determine whether the patient has received any other therapy services during the current benefit period. These services would apply to the threshold. The patient's progress towards the therapy threshold is calculated using the allowable fee schedule. Therapists can request a history of the therapy services a patient has received from CMS by contacting their Medicare contractor if the patient is unable to provide this information.
Understanding the Therapy Threshold Exceptions Process
The therapy threshold is not the ultimate limit of reimbursement for a particular patient. If a therapist believes that continuing therapy with a patient is medically necessary and thus qualifies the patient for an exception to the threshold, they simply need to attach the KX modifier to the charges (on a claim) that exceed the threshold and clearly document their reasons for continuing treatment.
Automatic Exceptions (KX Modifier)
By attaching the KX modifier to a claim, therapists attest that the services billed qualify for the threshold exception, are reasonable and necessary, require the skills of a therapist, and are justified by supporting documentation in the patient's medical record. The automatic exceptions process can be used to treat beyond the threshold.
Targeted Medical Review
If a patient's treatment expenses surpass $3,000, these claims may be subject to a targeted medical review. However, not all claims that exceed the threshold will be targeted for review. Instead, auditors will select claims above the threshold to review based on specific criteria.
Advance Beneficiary Notice of Noncoverage (ABN)
If a therapist would like to continue therapy for a patient who has exceeded the threshold but does not qualify for an exception, they can do so through the use of an Advance Beneficiary Notice of Noncoverage (ABN). An ABN notifies a Medicare patient that Medicare might not cover the therapy services they are about to receive and serves as proof that the patient understands their financial obligation.
Medical Necessity and the GA Modifier
The GA Modifier is used in Medicare billing to indicate that an Advance Beneficiary Notice of Noncoverage (ABN) has been issued to a patient. An ABN is a form given to Medicare patients when a service may not be covered or deemed medically unnecessary by Medicare. The GA Modifier is important for compliance and ensures that both the patient and Medicare are properly informed about potential non-coverage.
How the GA Modifier is Used
GA Modifier stands for "Waiver of liability statement issued, as required by payer policy." This means the provider has informed the patient that Medicare may not cover the specific service, and the patient has signed the ABN acknowledging that they may be financially responsible if Medicare denies the claim.
Conclusion
Understanding the Therapy Medicare Cap and its related elements such as the modifier KX, therapy threshold, Advance Beneficiary Notice of Noncoverage, and GA modifier is crucial for therapists. This knowledge ensures accurate physical therapy billing and compliance with Medicare regulations. As therapists navigate through the complexities of these regulations, the focus remains on providing medically necessary care to patients.