The 2010 Therapy Cap and Exceptions Process
The 2010 Medicare Part B outpatient therapy cap amount is $1,860 for occupational therapy services, and there is a combined cap amount for physical therapy and speech language pathology services of $1,860. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached. For more information on 2010 cap amounts, see Transmittal 1860 (Therapy Cap Values for Calendar Year (CY) 2010) and its corresponding MLN Matters article from the Centers for Medicare & Medicaid Services (CMS), as well as Transmittal 1894 (Billing for Services Related to Voluntary Uses of Advanced Beneficiary Notices of Noncoverage (ABNs)).
President Obama signed into law landmark health care reform legislation, the Patient Protection and Affordable Health Care for America Act (H.R. 3590, Pub.L. 111-148), on March 23, 2010. The law extends the therapy cap exception process through December 31, 2010. Each extension of the exceptions process has been piecemeal: previously, the Temporary Extension Act of 2010 included a provision extending the therapy cap exception process through March 31, 2010, and prior to that the Medicare Improvements for Patients and Providers Act of 2008 extended the exceptions process through December 31, 2009.
Occupational therapists may thus submit claims for medically necessary therapy services using the KX modifier and following all other ongoing requirements for therapy cap exceptions filings. The therapy caps are determined on a calendar year basis, so all patients began a new cap on January 1, 2010.
AOTA continues to educate Congress about the issues surrounding implementation of the therapy cap (as well as other scheduled and proposed cuts to Medicare payment for outpatient occupational therapy) and advocate for a permanent legislative fix. AOTA is also working with CMS and its contractors to develop alternatives to the therapy cap, specifically through the Short Term Alternatives for Therapy Services (STATS) and Developing Outpatient Therapy Payment Alternatives Project (DOTPA) research projects.
For updated information about our advocacy efforts in this area, as well as information about how to contact your members of Congress, please see the AOTA Legislative Action Center; for the latest information on claims filing and payment in your area, see your MAC web site; and for the most updated Medicare Manual guidance, see Transmittal 1985 (Clarifications and Updates of Therapy Service Policies). This page will be updated with additional guidance from CMS as it becomes available.
Please contact Jennifer Hitchon, AOTA regulatory counsel, with questions: firstname.lastname@example.org.
Updated: September 16, 2010.