Outpatient Therapy Caps Updated

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  • February 24, 2009
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The Centers for Medicare & Medicaid Services (CMS) updated the outpatient therapy cap exception policy and dollar amount for 2009.
Effective Jan. 1, the allowed outpatient therapy dollar limits, excluding outpatient hospital services, for physical therapy and speech-language pathology combined is $1,840 and for occupational therapy is $1,840. Providers who perform services meeting the exceptions criteria and report modifier KX Specific required documentation on file will be paid beyond this limit.

Outpatient therapy claims exceeding the 2008 amount of $1,810 per cap submitted between Jan. 1 and the implementation date of the new cap amount (April 6) without the modifier KX will be rejected. Providers should resubmit claims with modifier KX to circumvent the cap rejection.

Use modifier KX judiciously. Its use attests services are medically necessary and justification is documented in the medical record.

Providers should also inform Medicare beneficiaries of therapy limits and cap exceptions. The Notice of Exclusion from Medicare Benefits (NEMB) Form No. CMS 2007 may be used for this purpose until March 1. Thereafter, the Advanced Beneficiary Notice (ABN) is appropriate (not the ABN-G, which will also be discontinued as of March 1).
You should also make note that CPT® 0029T has been removed from the 2009 therapy code list.
This information and related coding and billing guidance can be found in Transmittal 1678, Change Request (CR) 6321, issued Feb. 13, as well as on the Therapy Services page of the CMS Web site.


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