Update on the 2015 Therapy Cap and Exceptions Process

As we move further into March, clinicians (and even patients) have been asking what to expect at the end of this month as the current therapy cap exceptions process expires.  As you may recall, the Protecting Access to Medicare Act of 2014, enacted on 4/1/14 and best known for delaying the implementation of ICD-10, also extended the therapy cap exceptions process through March 31st, 2015, allowing therapists to use the KX modifier in instances where they deemed additional care was medically necessary after the patient had met their annual therapy cap.  The act also extended the manual medical review process which applies to claims for services that exceed the $3,700 threshold of incurred expenses for each beneficiary.  Additional legislation is required to extend the exceptions and manual medical review processes beyond March 31st; otherwise, Medicare beneficiaries will be faced with a hard cap of $1,940 cap for physical and speech therapy services combined and a separate $1,940 cap for occupational therapy.

Currently, there are bills in both the House and Senate which aim to permanently repeal the therapy caps altogether. Considerable advocacy efforts have been directed towards supporting these bills.  The APTA has also advocated for the permanent repeal of the cap as part of the larger SGR reform package.  While a permanent repeal may not occur prior to the March 31st deadline, the expectation is that Congress will pass legislation to at least extend the exceptions process for the short-term in order to prevent Medicare beneficiaries from not having access to rehabilitation services or having to pay out-of-pocket for those services once they have reached their cap.  In the past, Congress has made provisions for the extension of the exceptions process, often at the 11th hour or, in at least one case, after the deadline had passed which resulted in considerable confusion as the exceptions process was later applied retroactively.

It will be important to stay informed as the March 31st deadline approaches so that your clinicians and patients will know how to proceed if and when Congress acts on the caps and/or the exceptions process.  More info can be found here as developments occur.