February 2010
Pending Legislation to Therapy Cap Values and Physician
Fee Schedule for 2010
John A. Miller
The Centers for Medicare & Medicaid Services (CMS) recently announced the therapy caps exceptions process will no longer be in effect as of January 1, 2010. Congress has temporarily set aside the extension of the exceptions process for Medicare Part B therapy until early in 2010.
As of January 1, 2010, there will be a $1,860 limit on occupational therapy (OT) services and a $1,860 limit on a combination of physical therapy (PT) and speech language pathology (SLP) services a beneficiary may receive during the 2010 calendar year, with no process for obtaining exceptions.
The Balanced Budget Act of 1997, P.L. 105-33, Section 4541(c) set annual caps for Part B patients. The Deficit Reduction Act of 2005 (signed Feb. 8, 2006) directed implementation of a process for exceptions to therapy caps for medically necessary services. Subsequently, the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) was enacted on July 15, 2008, and Section 141 extended the effective date of the exceptions process to the therapy caps to December 31, 2009.
January 1, 2010, also established the new Part B rates to be in effect from January 1, 2010, through February 28, 2010. The Department of Defense Appropriations Act, 2010, signed by President Obama on December 19, 2009, temporarily delayed the 21.2 percent cut in the Medicare Physicians Fee Schedule (MPFS) until February 28, 2010. However, the 2010 conversion factor was implemented on January 1, 2010, so the delay did not simply extend the 2009 rates. New provisional rates are in effect for January and February 2010, but if no further action is taken by Congress, the 21.2 percent fee schedule rate decrease will go into effect on March 1, 2010. The 2010 consolidated billing update included the addition of Healthcare Common Procedure Coding System (HCPCS) code 92520, Laryngeal function studies, to the list of Part B therapy services included in consolidated billing.
Stay Alert to Pending Legislation
The House of Representatives version of pending health care reform legislation includes a two-year extension, and the Senate version currently includes a one-year extension of the therapy exceptions process. Both of these provisions will retroactively reinstate the exception process for all Medicare beneficiaries receiving Part B therapy benefits provided on or after January 1, 2010. However, with recent delays in the health care reform process, the current status of the extension process is unclear.
CMS officials continue to work with Congress on significant legislation that affects the Medicare program, and they believe that some or all of these provisions will be extended as part of the current legislation.
How Does This Affect Those Receiving Services?
Some therapy companies have suggested the limitation of therapy caps has a definite and dramatic impact on treatment outcomes, with both length of services declining and functional gain of those patients receiving services being documented lower than those who fell under the exceptions.
Questions and Concerns
In the interim, claims for services furnished on or before December 31, 2009, will be processed as normal. For those services after January 1, 2010, CMS is recommending providers hold their claims—to the extent possible—until it becomes clearer. Contact CMS or your BKD advisor if you have further questions.
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