Outpatient Therapy Reaches Limit: See Exceptions
The exceptions to outpatient therapy caps expired on Dec. 31, 2009. Outpatient therapy service providers should not submit claims with modifier KX for services furnished on or after Jan. 1. Also effective Jan. 1, for physical therapy and speech language pathology services combined, the limit on incurred expenses is $1,860. For occupational therapy services, the limit is $1,860. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached.
Note that patients who have reached their limit(s) on outpatient therapy services, other than those who reside in a Medicare-certified part of a skilled nursing facility (SNF), may obtain medically necessary therapy services that exceed the caps if the services are furnished and billed by the outpatient department of a hospital. In other settings, outpatient therapy services in excess of the caps are not covered, and the therapy provider may charge patients for those services.