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Article 02/05/2019

Updates to Therapy Provisions & Functional Limitation Reporting

Nurse and Patient

Providers of therapy services were given some relief with the publication of the Bipartisan Budget Act of 2018 (BBA) and the 2019 Medicare Physician Fee Schedule (MPFS) Final Rule. Revisions to both policies affect the requirements for therapy functional limitation reporting and the application of therapy caps.

Functional Limitation Reporting

Effective January 1, 2019, therapy providers are no longer required to report the functional limitation Healthcare Common Procedure Coding System (HCPCS) codes G8978 through G8999 and G9158 through G9186 and the corresponding severity/complexity modifiers CH through CN.

MedLearn Matters Number MM11120 and the corresponding change request state this change won’t be implemented until February 26, 2019. In addition, CMS noted in the 2019 MPFS that this code set and modifier range will remain active until calendar year 2020 when the HCPCS codes and modifiers will be inactivated, which will facilitate the phaseout of this code and modifier set by other payors.

While the functional limitation claims-based reporting requirement is being lifted, the therapy documentation requirements outlined in the Medicare Benefit Policy Manual, Chapter 15, Section 220.3 aren’t being rescinded. These guidelines continue to require documentation of objective, measurable beneficiary physical function in the patient’s medical record. Therefore, while the claim reporting requirements are lifted, the previously established therapy assessment and documentation requirements remain.

Outpatient Therapy Caps

Effective January 1, 2019, with an implementation date of February 26, 2019, the BBA repealed the application of therapy caps. While the cap has been repealed, CMS is retaining the previous therapy amounts as a threshold for application of the KX modifier. Once a patient exceeds the therapy threshold, the provider must append the KX modifier to receive reimbursement for therapy services. Without the KX modifier, claims will be denied when the threshold has been exceeded. The KX modifier is certifying to the Medicare Administrative Contractor that the services are medically necessary, are documented in the patient’s medical record and qualify for the KX payment exemption.

The 2019 MPFS lists the therapy thresholds as $2,040 for combined physical therapy (PT) and speech language pathology (SLP) services and $2,040 for occupational therapy (OT) services.

The BBA also retains the targeted medical review threshold of $3,000 for combined PT and SLP services and $3,000 for OT services. The targeted review process subjects some, but not all, claims over the established threshold to a medical review process.

For more information, contact Jen or your trusted BKD advisor.


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