CMS Releases Information on Outpatient Therapy Services Claims

May 3, 2012

The Centers for Medicare and Medicaid Services (CMS) has released the first of numerous transmittals on the implementation of the Middle Class Tax Relief and Job Creation Act of 2012 which includes a revision for processing outpatient therapy claims. The transmittal instructs providers to continue to use the –KX modifier for the exceptions process on claims for therapy services exceeding the 2012 cap amount of $1,880 for combined services for speech-language pathology and physical therapy. It also explains that as of January 1, 2012, therapy services furnished in an outpatient hospital setting will contribute toward the cap that is effective as of October 1, 2012. Hospital outpatient claims over $1,880 will also require the –KX modifier beginning October 1. This is the first time that hospital outpatient services have applied toward the therapy cap.

Two additional requirements of the legislation include the insertion of the physician NPI (or nurse practitioner or physician assistant) who is certifying the therapy plan of care and a manual medical review process when combined claims for speech-language pathology and physical therapy services reach $3,700, beginning October 1, 2012. CMS clarifies that, while the use of an Advance Beneficiary Notice of Noncoverage (ABN) is not required, providers are encouraged to issue a voluntary ABN as a courtesy to their patients for therapy services above $1,880 that may not be granted an exception.

The transmittal is posted on the CMS website. For more information, please contact Lisa Satterfield, ASHA's director of health care regulatory advocacy, at

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