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The therapy cap reborn

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Jean Wendland Porter
Jean Wendland Porter

Editor's note: This piece has been updated to clarify the G0515 code.

At the end of 2017, Congress recessed before a decision was made on the repeal of the Part B Therapy Cap that we've been living with, working around, and appealing since 1998. Then the government shut down.

Then it was reopened for three weeks, without any decisions made on the Part B Therapy Cap. The new cap for 2018 is $2,010 for physical therapy/speech therapy combined, and $2,010 for occupational therapy. What has changed is that the Exceptions Process, which we've come to embrace and rely on using the -KX modifier, allowing us to offer therapy if the therapy continues to be skilled past the cap, is also gone. This new cap is hard and immutable.

This means that your Medicare beneficiaries become liable for ALL therapy charges after they reach the arbitrary and unreasonable Cap of $2,010.

All charges.

For the entire year.

In all my years of practice, I've encountered very few geriatric patients who only required that among of therapy for the year. Roughly $2,000 of PT/ST gets used in the first month of treatment, even for low frequency patients.

What can we expect? Well, we're comforted by the fact that Congress has either offered a moratorium on the cap or extended the Exceptions Process every year since the cap's inception. We won't know the ultimate outcome until Congress gets their act together and passes the Medicare Access to Rehabilitative Services Act that will end the therapy cap and implement a comprehensive targeted medical review process. Alternatively, they may just extend the Exceptions process. Or they may ignore both and implement the hard cap.

What else can we expect? For one, the G0515 Cognitive Cog is still timed, but the non-Medicare CPT of 97127 is not time or related to caps. 

Additionally, RVUs for these services may increase or stay the same. However, these will not impact therapy reimbursement in a meaningful way.

So what do we do? How can we help and manage our patients, manage reimbursement, and manage systems in the possible eventuality of limited Part B access for therapy, and the potential for the enormous reimbursement changes in Part A that we're expecting in October?

Like anything else we've been forced to accept, we will adjust and accommodate. But before we cave and allow one more insult and offense to our practice, we need to contact our Congress-people and remind them of the need for our seniors to get the services that they have paid for all of their adult lives. Arbitrarily capping reasonable and necessary services for our geriatric patients and eventually for us, is damaging and detrimental. 

Don't know who your representatives are? Enter your ZIP code into https://www.house.gov/representatives/find-your-representative and email them, call them, or fax them. We can't allow restrictions on our practice that will harm our patients.


Jean Wendland Porter, PT, CCI, is the Regional Director of Therapy Operations at Diversified Health Partners in Ohio.
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