Medicare therapy cap changes effective March 1, 2020

Starting March 1, 2020, we're making changes to our Medicare therapy caps for physical, occupational and speech therapies (PT/OT/ST). We're making these changes based on recent changes from the Centers for Medicare and Medicaid Services (CMS), and to align with their guidelines.

Guidelines for billing Medicare outpatient therapy services, effective March 1, 2020

The following guidelines apply for claims received beginning March 1, 2020: 

  • Providers need to track member's therapy services to $2,080.
  • Claims received between $2,080 and $3,000 must include the KX modifier to be paid.
  • Claims received at $3,000, or greater, must include the KX modifier. Providers must also submit medical records to confirm the services are medically necessary.
  • Providers billing through EDI will need to either submit a paper claim with medical records or mail the notes separately with the member's ID number included.

For additional information about Medicare therapy cap limits and CMS' position, reference MLN Matters 11532.