No Therapy Cap Exceptions for 2018

No Therapy Cap Exceptions for 2018.jpg

By:Jacqueline Thelian, CPC, CPC-I, CHCA

Beginning January 1, 2018, the cap on physical therapy services has a slight increase to $2,010.00.  That’s the good news.

The bad news, the “exception process” which would allow the continuation of PT services up to $3,700.00 with the use of the “KX” modifier (Requirements specified in the medical policy have been met) is no longer applicable. 

Additionally, the manual review process for claims that would exceed the $3,700.00 is also no longer a valid option.

The Final Rule which put the end to the exception process states, “Without a therapy cap exceptions process, the statutory limitation requires that beneficiaries become financially liable for 100% of expenses they incur for services that exceed the therapy caps” The rules goes on to state, “the therapy caps will be applicable without any further medical review, and any use of the “KX” modifier on claims for these services by providers of outpatient therapy will have no effect.” In short, without the renewal of the exception process:


  • CMS will deny reimbursement of any claims that exceed the current therapy cap of $2,010.00
  • Medicare beneficiaries will be responsible for claims over the cap amount of $2,010.00
  • The KX modifier for Physical Therapy claims will have no impact on the claims

So, what can you? Providers can issue Advanced Beneficiary Notices (ABNs). The ABN is a notice of non-coverage which advises the Medicare beneficiaries of non-coverage and their financial responsibility for therapy over the cap. Click on the link below to brush up on how to complete the ABN.