Medicare Part B Therapy Cap Update

VHCA (1/8/2010)

Although the exceptions process for the Medicare Part B therapy cap expired at the end of 2009, Congress is expected to address the issue and pass a retroactive extension early this year.  In fact, both the House and the Senate versions of health care reform contain extensions. 

In order to address the December 31, 2009 expiration of the therapy cap exceptions process, the Centers for Medicare & Medicaid Services (CMS) has issued a Medicare Learning Network (MLN) Matters Article, which is available here.

In the article, CMS indicates that claims for services furnished on or before December 31, 2009, will be processed as before. The CMS communication further states, “For services provided on or after January 1, 2010, health care providers may choose, to the extent possible, to hold their claims (that is, not submit their claims to Medicare) until it becomes clearer as to whether new legislation will be enacted to extend these provisions.”

The CMS article cautioned providers that for claims exceeding the cap “submitted with dates of service on or after January 1, 2010, will not be paid in accordance with the expired provisions.” CMS has committed to communicate openly about this issue, and anticipates forthcoming alerts as the situation changes.

The therapy caps are determined on a calendar year basis, so all patients will begin a new cap year on January 1, 2010. For physical therapy and speech language pathology services combined, the limit on incurred expenses is $1,860. For occupational therapy services, the limit is $1,860. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached.