By: Lorna Simons, CPC
Medco Consultants, Inc
Great news! The therapy cap will be going up for 2018. Announced on November 9, 2017, the therapy cap will be going from $1,980 to $2,010.
Therapy caps were created under Section 4541 of the Balanced Budget Act to financially limit the Outpatient Therapy services provided to Medicare beneficiaries. Speech Language Pathology (SLP) and Physical Therapy share a cap while Occupational Therapy has separate cap.
It is important to remember, when coding therapy services, to append the appropriate modifier to the services so that it is applied to the right cap. Certain CPT codes considered “always therapy” codes, as well as any service performed in a Therapist in Private Practice (TPP) setting, should be appended with the appropriate modifier.
- Modifier GN- Services delivered under an outpatient speech language pathology plan of care
- Modifier GO- Services delivered under an outpatient occupational therapy plan of care
- Modifier GP- Services delivered under an outpatient physical therapy plan of care
Exceptions can be made to the therapy caps based on the patient and medical necessity, however, it is important to note that providers who routinely go beyond the therapy caps can be subject to post-payment reviews. While MACRA has eliminated the manual medical review requirements for services over therapy threshold ($3,700), providers with a high patient population receiving therapy beyond the cap threshold may be selected for review.
American Medical Association Current Procedural Terminology Manual (CPT) 2018
Healthcare Common Procedure Coding System (HCPCS) 2018
Manual Medical Review of Therapy Claims above the $3,700 Threshold, https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/TherapyCap.html
Pub 100-04 Medicare Claims Processing, Transmittal 3918, https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3918CP.pdf
MLN Matters number MM10176, Updated Editing of Always Therapy Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10176.pdf
Pub 100-04 Medicare Claims Processing, Transmittal 3863, https://www.cms.gov/regulations-and-guidance/guidance/transmittals/2017downloads/r3863cp.pdf