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News & Press: Government Affairs News

CMS Releases Some Held Therapy Claims

Friday, January 26, 2018   (0 Comments)
Posted by: Bradley Coffey, MA, AAOE Government Affairs
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Baltimore, MD - The Centers for Medicare and Medicaid Services (CMS) announced today that the agency will begin processing some physical and occupational therapy claims. Claims dated between January 1 and January 10, 2018 using the KX modifier will be immediately released for processing. CMS will continue to process physical and occupational therapy claims that do not use the KX modifier.

Beginning January 31, CMS will release claims for processing one day at a time based on the date the claim was received. For example, if the claim was received on January 11, the claim will be released for processing on January 31; if the claim was received on January 12, the claim will be released for processing on February 1. CMS will also implement a rolling hold of 20 days on physical and occupational therapy claims "to help minimize the number of claims requiring reprocessing and minimize the impact on beneficiaries if legislation regarding the therapy caps is enacted."

The exceptions process for therapy claims over the cap limit expired on December 31, 2017 after Congress failed to reauthorize the process. Under the statutorily created therapy caps, beneficiaries exceeding the therapy cap in 2018 of $2,010 will have their physical therapy claims denied and the reimbursement for therapy services will fall to the beneficiary. This is a hard cap, meaning that if the exceptions process is not renewed, there are no appeals for the patient to obtain Medicare coverage over the $2,010 cap.

The KX modifier, which this policy affects, is used when a patient has exceeded the therapy cap and alerts Medicare that the patient has exceeded their allowed therapy services for the benefits year.


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