Therapy Cap Repealed by Congress. Will Your Part B Claims Hold Up in Post-Pay Audit?

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How will your Part B therapy claims hold up in audit?

Earlier this week, congress passed legislation that permanently repeals the Part B therapy caps. Since 2006, the exception process allowed providers to bill for therapy above cap limits ($2010 annually for PT/ST combined and $2010 annually for OT) with the application of modifiers to indicate the services were medically necessary. However, the exception process ceased at the end of 2017. With no exception to this process, Medicare recipients were at risk of limited access to needed therapy services to restore function, improve quality of life and in some cases even to return home.

This new law permanently removes the monetary annual therapy cap for physical therapy, occupational therapy and speech therapy. The repeal is retroactive to Jan. 1, 2018. So, any SNF’s who have had Medicare B therapy claims denied due to exceeding the therapy cap, should resubmit the claim for payment. The application of the KX modifier, to indicate therapy delivery above the monetary cap limit for year will still be necessary as an attestation of medical necessity.

Will your claims hold up in post payment review?

CMS will restore a targeted medical review program for certain claims that exceed a $3,000 annual threshold. Post pay medical reviews will be conducted by CMS on targeted groups, i.e. pattern of high costs within similar patient populations, or similar types of providers.

• Therapy services must be reasonable and necessary. To ensure this, rehab managers should be familiar with Coverage Guidance in their Local Coverage Determination and with CMS (Pub. 100-02, MBPM, Ch 15, sec 220-230)

https://www.cms.gov/medicare-coverage-database/indexes/lcd-state-index.aspx
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

• Evidence that the therapy plan of care has been reviewed by the physician or Non-physician practitioner, dated and signed plan of care or other document
• The Med B claims contain the appropriate functional reporting, using G codes and appropriate modifiers every 10 visits
• Required elements of the treatment plan must be in place (diagnosis, long term goals, type/amount/duration/frequency of treatment)
• Progress reports must be in place every 10th treatment at a minimum
• Documentation on each treatment should include total “Timed Code Treatment Minutes” and “Total Treatment Time” in minutes
• Documentation each treatment must also include the signature and professional identity of the qualified professional who furnished the treatment.

A team approach, using a checks and balances system should be established for your Medicare Part B claims, similar to a PPS Triple Check. Now that Congress has paved the way for Medicare Part B recipients in need of medically necessary therapy services, don’t let these types of technical requirements prevent your claims from being paid!

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