As you know, our Medicare systems have been going through ongoing adjustments to find ways to maximize clinical effectiveness and contain costs. We have been operating under a therapy cap for our patients that receive services billed to Medicare B. This mostly affects long term care patients in a SNF and patients receiving outpatient therapy. Currently, patients have a therapy cap of $1880 per calendar year that is shared with speech and physical therapy. Therapists have readily been able to provide services beyond the therapy cap using a provision called the “Exception Guidelines.” The billing department simply adds an additional code (KX modifier). Therapists then keep documentation supporting the additional therapy services as being reasonable and necessary.
A recent article by Lisa Satterfield in the July 3rd ASHA Leader states that effective 10/1/2012, the Centers for Medicare and Medicaid Services (CMS) will begin “manual medical reviews” of Medicare B claims that exceed $3,700 for services rendered by an SLP. This new review will be used in conjunction with the KX modifiers to help CMS contain costs and make sure that the services rendered are both medically necessary and justified.
Lisa suggests therapy providers give patients the voluntary advance beneficiary notice (ABN letter) if they anticipate exceeding the $1880 therapy cap. This informs patients they may be financially responsible for therapy costs if CMS does not agree that their treatment plan is reasonable and necessary. For more information visit:
. Please feel free to contact me if you have any questions about the new procedures.
Beth Wilcox (firstname.lastname@example.org)