11th Aug

Medicare Part B Therapy Caps

I remember about ten years ago when my dad had his first hip replacement and was excited when he finally “graduated” from home health Physical Therapy (PT), which allowed him to go to Outpatient Physical Therapy. He was elated. He went to his Outpatient PT evaluation and was ordered PT three times a week for Outpatient PT. When he and I discussed his Outpatient PT plan of treatment, I asked him about his benefit coverage and if the Outpatient Physical Therapist explained his coverage under Medicare Part B. He told me that the receptionist did talk to him about it and “everything is covered! I have Medicare Part B and AARP so even my co-pay is covered”. I showed my excitement for him but then I gently said, “So you are good with the Medicare Part B cap as well?” He looked at me funny and then said that he didn’t know what I was talking about. When I explained it to him, he was furious! He said he didn’t have a clue that there was a cap on the amount of therapy he can get and Congress “needs to get their act together”. He called his State Representative and Senator and voiced his opinion. He and my mom began to advocate for repealing the caps through the link that I provided to them from National Association for the Support of Long Term Care (NASL). My dad’s PT rehab was favorable and he eventually could walk without his cane but doing so came long after his Medicare Part B cap amount and threshold was exhausted. See, the Medicare Part B cap and threshold didn’t consider the debilitating state that my father’s joint was in, the club foot he has been suffering with all his life, and the comorbidity impact of his spinal stenosis. The dollars were met, he was discharged from PT, and no more therapy for that year!

What are the Therapy Caps and Threshold? Let’s review:

  • Physical Therapy and Speech Therapy (ST) share a bucket of Medicare Part B dollars per calendar year and Occupational Therapy (OT) has their own bucket of dollars.
  • In the PT/ST “bucket” is $1,980 for 2017 and in the OT “bucket”, there is $1,980 for 2017.
  • Once the dollars are spent in each bucket, and before reaching the $3,700 threshold, that space between the cap ($1,980) and the threshold ($3,700) is where the exceptions process comes into play.
  • If the skills of a therapist are vital to treat the patient’s condition and the services are medically necessary, with the addition of a KX modifier on the claim, therapy can continue to provide the services.

Times haven’t changed much since my dad’s first hip replacement. And yes, we are still dealing with Medicare Part B Therapy Caps…for 20 Years Now! We should be grateful as providers, that Congress stopped the “hard cap” on services, which at one time we were dealing with. But when the “hard cap” went away, we were burdened with multiple, temporary alternatives, and the “exceptions processes”. The “exceptions process” has provided relief to providers and allowed the medically necessary care to beneficiaries over the cap. But at times, the process has been a pain in the neck.

A few years back, as providers, we had to obtain prior authorization through the Medicare Administrative Contractor (MAC) to continue therapy past the cap amount. This pre-approval process left patients not receiving the medically necessary care they required while the provider was waiting on the MAC’s decision. At times providers would receive no authorization to continue, would receive approval for a limited number of visits that would not meet the needs of the beneficiary, and providers even received an approval letter one day followed by another letter denying approval for the same beneficiary the very next day, and the list of issues goes on and on.

NASL has informed providers, “Congressional leadership has shown real interest lately in fixing the therapy cap once and for all, and a successful Energy and Commerce Health Subcommittee hearing was recently held in the House. Now is the time to make sure there is great demonstration of Congressional support for a permanent fix!”

We can’t do it alone, though. We need your help. Please join Functional Pathways and NASL in urging Congress to revisit this critical issue before the exceptions process expires at the end of 2017. It only takes a minute by clicking on the appropriate link below.



Part B Link for Patients

Part B Link for Family Members

Part B Link for Providers



Gina Tomcsik

Director of Compliance

Functional Pathways

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