Medicare therapy cap changes effective Jan. 1, 2019

On February 9, 2018, President Trump signed into law the Bipartisan Budget Act of 2018 (BBA of 2018) (Public Law 115-123). This new law includes two provisions related to Medicare payment for outpatient therapy services including physical therapy (PT), speech-language pathology (SLP), and occupational therapy (OT) services.

In response, in August 2018 CMS announced its therapy cap changes publicly via email to subscribed providers and on the CMS website. The changes take effect on Jan. 1, 2019.

Priority Health aligns with CMS

In following with CMS methodology for our Medicare Advantage plans, Priority Health therapy caps align with CMS.

We will be following the suggested medical review at $3,000 threshold:

  • Providers need to track member's therapy services to $2,040 ($2,040 for physical and speech therapy, and an additional $2,040 for occupational therapy).
  • From $2,040 and beyond, bill with KX modifier. For services not billed with the KX modifier, claims will be denied as "resubmit with a valid modifier."
  • At the $3,000 threshold amount, providers should submit medical records to demonstrate medical necessity. If notes are not submitted, claims will "deny for medical records."
  • Providers billing through EDI will need to either submit a paper claim with the notes or mail the notes separately with member ID included.

More information

Find additional information on the CMS website about therapy cap limits and CMS' position.