Health Information Management

Q/A: Therapy caps under OPPS

APCs Insider, August 24, 2012

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Q: Our outpatient rehabilitation services director is concerned about the therapy caps related to physical, occupational, and speech therapies. I keep telling him that hospitals are excluded under the OPPS, but he keeps arguing with me about it. Is there something new about these caps?

 
A: Up until now, hospital outpatient therapy departments have been excluded from the therapy caps, but beginning October 1, this will no longer be the case. The therapy cap amounts for CY 2012 are $1,880 for occupational therapy and $1,880 for physical and speech therapy combined. The Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA), Section 3005, made several changes to the policy. For services provided from October 1, 2012, through January 1, 2013, the thresholds will increase to $3,700 for the year.
 
The act also requires that hospital outpatient therapy services for original Medicare be included in the amount subject to the cap as well as other related provisions. All therapy services provided by hospital outpatient therapy departments for CY 2012 will be included in the calculation to determine if the cap amount has been reached, even though the cap only applies to hospital outpatient therapy services for dates of service from October 1 through December 31. The impact is that the beneficiary will more quickly reach the cap amount.
 
While modifier -KX can still be used to request an exception to the cap threshold, providers should keep in mind that this modifier attests to CMS that the documentation in the record supports the reasonableness and medical necessity of the extended therapy. Beginning October 1, 2012, all services with the modifier appended will trigger a manual medical review. The exceptions process is set to expire at the end of 2012, so this may be a temporary situation for dates of service from October 1 through December 31 unless Congress steps in.    
 
For more information, see Transmittal R2457CP.
 
Editor’s note: Denise Williams, RN, CPC-H, vice president of revenue integrity services at Health Revenue Assurance Associates, Inc., in Plantation, Fla., answered this question.



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