Therapy Cap Advocacy Center

Latest Developments

• Medicare Fees and Therapy Cap Exceptions Process Addressed In Fiscal Cliff Legislation (1/3/2013)

Background on Therapy Caps

The current therapy cap is $1,900 for speech-language pathology and physical therapy combined.

The Medicare cap on outpatient rehabilitation therapy services was originally instituted under the Balanced Budget Act of 1997 as a combined cap on speech-language pathology (SLP) and physical therapy (PT) services, as well as a separate cap on occupational therapy (OT) services to Medicare beneficiaries.

The original $1,500 cap on Part B Medicare therapy services was intended as a cost control mechanism, but has not proved effective in saving Medicare money. Instead, the sickest of Medicare patients were being denied needed care. Congress has recognized that a financial limitation on therapy is detrimental to Medicare patients and through the years placed numerous moratoriums on its implementation.

On January 3, 2013, the president signed the "American Taxpayer Relief Act of 2012" into law. The law directs the Centers for Medicare and Medicaid Services (CMS) to continue to allow exceptions to therapy caps for medically necessary services provided through December 31, 2013. The law also extends through December 31, 2013:

• the use of an NPI number for the physician reviewing the need for therapy;
• required use of the KX modifier on claims above the cap;
• the manual medical review process for expenditures that reach $3,700 for speech-language pathology and/or physical therapy services; and
• the application of the therapy cap and exceptions process to hospital outpatient departments.

The new law also applies to therapy expenditures provided in critical access hospitals (CAHs) for outpatient services toward the total dollar amount in the therapy cap.

Updates to instructions and implementation from CMS will be shared via ASHA Headlines and posted on ASHA's Billing & Reimbursement website.

Advocate

Here are some simple things you can do to help improve the therapy benefit:

• Participate in NOMS and PQRS for outcomes measures
• Use ASHA's Take Action site to contact Congressional representatives and ask them to repeal the therapy caps
• Set up a computer in your office and ask patients to write letters through ASHA's Take Action site
• Sign up for ASHA Action Alerts

Additional Resources

• Therapy Cap Exceptions Process
• CMS Therapy Cap webpage

Archives—ASHA's previous advocacy efforts on the Medicare Therapy Cap Advocacy Campaign