Medicare patients who receive routine therapy may need to be careful during 2018. This year, the Medicare therapy cap sits at $2,010 for the combined total for all physical therapy (PT) and speech-language pathology (SLP), while occupational therapy (OT) has the same upper limit. As of the first of the year, Congress had adjourned for the holiday break without deciding on a plan for ending the cap or even addressing the exceptions process. With plenty of other items up for debate during the next session, it’s anyone’s guess as to when this issue will finally be resolved.
Under this therapy cap, any additional therapy past the limit will not be included as a Medicare benefit. This rule applies to all locations except for hospitals, although critical access hospitals are not immune. In years past, patients had the option of appealing the therapy cap and gaining exceptions, but the previous guidelines for this process expired at the end of 2017. In the absence of new guidelines, the Centers for Medicare & Medicaid Services (CMS) are simply not allowing exceptions.
Currently, the new plan is for a new exceptions process to be decided upon by the end of January, but few are optimistic about the timeline holding firm. In the meantime, CMS does not anticipate that many Medicare patients will exceed the therapy cap by the end of the month, and they have reiterated that all fees past the $2,010 mark will be the sole responsibility of the patient.
Although nothing was officially acted upon, the Senate and the House of Representatives did at least reach a general consensus for ending the therapy cap back at the end of 2017. Under this proposal, the cap would be permanently be replaced with a manual review process for any therapy claims greater than $3,000. However, only time will tell if this proposal will become a reality. If you work as a biller for a facility that treats a high number of Medicare therapy patients, be sure to monitor each patient’s cap and to keep an eye out for any new updates from Congress and CMS.