September 5, 2012
Medicare Part B Outpatient Therapy Cap and Exceptions Process Extended Through December 31, 2012
The Middle Class Tax Relief and Job Creation Act of 2012 (H.R.3630) was signed into law on February 22, 2012; extending the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2012.
The statutory Medicare Part B outpatient therapy cap for Occupational Therapy (OT) is $1,880 for 2012, and the combined cap for Physical Therapy (PT) and Speech-Language Pathology Services (SLP) is also $1,880 for 2012.
Similar to the therapy cap, Congress established a threshold of $3,700 for PT and SLP services combined and another threshold of $3,700 for OT services.
All therapy services rendered above the $3,700 are subject to manual medical review and certain providers will be required to submit a request for an exception.
The therapy cap applies to all Part B outpatient therapy settings and providers including:
o Private practices
o Part B skilled nursing facilities
o Home health agencies (TOB 34X)
o Outpatient rehabilitation facilities (ORFs)
o Rehabilitation agencies (Comprehensive Outpatient Rehabilitation Facilities-CORFs)
o Hospital outpatient departments (HOPDs) – beginning October 1, 2012 until December 31, 2012
Exception Requirement Changes:
Beginning on October 1, 2012 some therapy providers will be required to submit requests for exceptions (pre-approval for up to 20 therapy treatment days for beneficiaries at or above the $3,700 threshold).
This requirement will not be imposed on all therapy providers at one time, it will be phased in, and therapy providers will be assigned to three groups or phases. Depending on which of the three groups or phases you are assigned:
Phase 1 – October 1 to December 31, 2012
Phase II – November 1 to December 31, 2012
Phase III – December 1 to December 31, 2012
Providers of physical therapy, may receive a letter titled “Notification of Request for Exception Requirements for Therapy”, indicating your assigned phase.
GO TO THE BELOW WEBSITE TO IDENTIFY YOUR PHASE BY YOU NPI NUMBER:
If you do not find your NPI number on the list, then you are in Phase III.