By Dr. John R. Mishock
What is the Medicare Physical Therapy Cap?
In 1997, as part of the Balanced Budget Act, a $1,500.00 cap ($2010.00 for 2018) on outpatient physical therapy and occupational therapy services was imposed. Meaning the maximum paid by Medicare for therapy services would be $1,500.00. Each year after this, congress would pass a moratorium to allow Medicare patients to extend past the $1,500.00 as long as the provider could prove medical necessity.
Currently, is there a Medicare hard Cap on Physical Therapy? No
As of January 1, 2018, congress abolished the hard cap on physical therapy and occupational therapy benefits.
Are there limits on physical therapy services for Medicare patients? No
Medicare beneficiaries are eligible for physical therapy services indefinitely with no monetary limitation as long as their health care provider (physician, physician assistant, nurse practitioner, or dentist) confirms their need for physical therapy.
If the Cap was abolished why is there $2010.00 therapy cap for 2018?
If a Medicare recipient exceeds $2010.00 in therapy payments the provider will need to use a KX modifier for attestation that the services are medically necessary. Medicare will still pay claims beyond this point as long as the provider justifies medical necessity.
What happens if I exceed $3,000.00 in therapy services?
Prior to 2018, if a Medicare patient exceeded $3,700.00 it would trigger an automatic review by Medicare of the provider to determine if the treatment was medically necessary. Now, if the annual claims are greater than $3,000.00 in therapy services it will not automatically trigger a medical review. A Medicare review will be selectively placed on a small percentage of providers who meet certain criteria such as; those who have had high claims denied, or those who have aberrant billing patterns compared with their peers.
Will I lose Medicare coverage if I have a chronic illness? No
Under a 2013 court settlement, patients will not lose coverage simply because they have a chronic disease that is not improving. As long as your health care provider deems the physical therapy treatment medically necessary, physical therapy services will be paid for to maintain the patient’s condition, prevent or slow decline. There is no arbitrary limit on how much Medicare will pay for physical therapy services.
If pain is limiting you from doing the activities you enjoy, give Mishock Physical Therapy a call for a Free Phone Consultation at (610)327-2600 or email your questions to email@example.com.
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