Medicare claims for therapy services provided after Dec. 31, 2017, are no longer subject to caps.

Avoid delays—know these changes

Excerpted from page 46 of the June 2018 edition of AOA Focus.

To ensure there is not a delay in processing of your claims, it's critical to stay on top of coding changes and to use correct coding. Below are a few updates and tips to keep you up to date.

"Claims for certain therapy services exceeding $3,000 may be subject to a targeted medical review process."

Medicare repeals payment cap for therapy services

Medicare claims for therapy services provided after Dec. 31, 2017, are no longer subject to caps. The cap was repealed by the Bipartisan Budget Act of 2018. Members billing Medicare for therapy services should note that:

  • Claims exceeding $2,010 should contain an appropriate modifier, such as the KX modifier, to indicate medical necessity and appropriate documentation in the medical record.
  • Claims for certain therapy services exceeding $3,000 may be subject to a targeted medical review process.  

The following factors may trigger a targeted medical review process for therapy services exceeding $3,000:

  • High claims denial percentage or is less compliant with applicable Medicare program requirements;
  • Pattern of billing for therapy services that is aberrant compared with peers or otherwise has questionable billing practices, such as billing medically unlikely units of services in a day;
  • Newly enrolled or has not previously furnished therapy services under the Medicare program;
  • Provides services to treat a type of medical condition; or
  • Is part of a group that includes another therapy provider identified by the preceding factors.  

Reporting for the Merit-based Incentive Payment System (MIPS) via claims? Make sure you are using the correct codes!

The Centers for Medicare & Medicaid Services made a last-minute change to the quality data codes for Measure 14, Age-Related Macular Degeneration: Dilated Macular Examination, in early 2018. Ensure you are using the correct codes for this measure.


Access AOACodingToday, a free member resource, to assist you immediately with your coding questions.

June 20, 2018

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