2-05-10
Therapy Cap Exceptions Process Expires - What to Do About Filing Claims
Update February 5 - AOTA continues to monitor CMS for guidance on how therapy services may be provided to patients whose occupational therapy services have exceeded Medicare's $1,860 cap. The latest guidance from CMS on this issue comes from Transmittal 1860 (Therapy Cap Values for Calendar Year (CY) 2010) and Transmittal 1894 (Billing for Services Related to Voluntary Uses of Advanced Beneficiary Notices of Noncoverage (ABNs)), but please watch this page for additional updates and analysis as it becomes available.
In the meantime, see this article on AOTA's ongoing advocacy in this area and information about how to contact your members of Congress to extend the exceptions process.
What to Do About Filing Claims in January
The therapy cap exceptions process expired December 31, 2009, which means that the claims filed starting January 1, 2010, will be subject to the $1,860 cap on occupational therapy services. For more information, please see Transmittal 1860 and the MLN Matters article from the Centers for Medicare & Medicaid Services (CMS) which state the amount of the cap for 2010.
AOTA has learned that CMS and contractors are advising providers to discontinue use of the KX modifier. For example, CMS contractor First Coast Service Options, Inc. posted an announcement stating:
Providers may choose to hold their claims in the event legislation about this issue is enacted. However, current law mandates the following change: The exceptions to outpatient therapy caps expire on December 31, 2009. Outpatient therapy service providers should not submit claims with the KX modifier for services furnished on or after January 1, 2010.
Further, CMS has issued a new MLN Matters article on the topic stating:
This special edition article is being issued by the Centers for Medicare & Medicaid Services (CMS) to notify affected providers that a number of Medicare payment provisions, such as the Therapy Cap Exceptions Process and Allowing Independent Laboratories to Bill for the Technical Component of Physician Pathology Services Furnished to Hospital Patients, will no longer be in effect when the provisions sunset as of December 31, 2009.
CMS continues to work with Congress on significant legislation which affects the Medicare program. We believe some or all of these provisions may be extended as part of this legislation. We encourage you to monitor activity on the Hill and stay apprised of the status of potential legislation. In the meantime, if such legislation is enacted, Medicare will notify its contractors to again process claims consistent with the extended provisions.
Although an extension of the exception process is included in the health care reform bills now being debated in Congress, those bills will not be finalized at least until later in January, at the earliest. AOTA continues to work with Congress to educate them about the problems caused by implementation of the cap at any time.
In addition, because of pending changes to the fee schedule payment amounts, on Monday December 21, 2009, CMS announced that it has instructed contractors to hold claims containing services paid under the Medicare Physician Fee Schedule (MPFS) for the first 10 business days of January (January 1 through January 15). This announcement was superseded December 23 by another notice from CMS which stated that they are holding claims to “avoid disruption in the delivery of health care services and payment of claims” while Congressional action is still in play.
A temporary fix to the MPFS cuts was signed by the President. CMS will still require time to adjust its payment systems, hence the 10-day hold on claims. Your MAC Web site is an important resource for the latest information applicable to your area.