The Medicare Therapy Cap is repealed!”
On February 9th, President Trump signed the latest funding bill into law, which included the Permanent Repeal of the Medicare Therapy Cap!
This means for the calendar year 2018, there is no hard therapy cap of $2010 for physical and speech therapy combined or a separate $2010 for occupational therapy. Great news!
Here is the not so good news! Providers would still need to track the Medicare allowed the amount for each CPT code as the KX modifier will still be required on claims that exceed the $2010 for physical and speech therapy combined and claims that exceed $2010 for occupational therapy in 2018. The required use of the KX modifier is for attestation that services are MEDICALLY NECESSARY. In addition, the manual medical review threshold has been reduced from $3700 to $3000 for physical and speech therapy combined and a separate $3000 for occupational from 2018 – 2027. This requirement does include outpatient hospitals and critical access hospitals.
Special Requirements for Therapists Who Provide Orthotics
On January 12, 2017, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule which would specify the qualifications needed for qualified practitioners to furnish and fabricate, and qualified suppliers to fabricate prosthetics and custom- fabricated orthotics; accreditation requirements that qualified suppliers must meet in order to bill for prosthetics and custom-fabricated orthotics; requirements that an organization must meet in order to accredit qualified suppliers to bill for prosthetics and custom-fabricated orthotics; and a timeframe by which qualified practitioners and qualified suppliers must meet the applicable licensure, certification, and accreditation requirements. In addition, this rule would remove the current exemption from accreditation and quality standards for certain practitioners and suppliers.
This proposed rule, if finalized, would have a significant impact on physical therapists (PTs) and occupational therapists (OTs) who currently provide custom fabricated orthotics to their patients.
Well, CMS has made their decision and the decision is the proposed rule has been withdrawn and there will be no changes to the qualifications needed for qualified practitioners (PTs and OTs) to furnish and fabricate as well as to bill for custom fabricated orthotics.
Thank you to all our members, TOTA members and fellow therapists that wrote letters to CMS and to our Legislators, as well as to the ones that visited Austin this year for Capitol Day. Your efforts paid off and now we can all enjoy doing what we do best. Together we can triumph!!!
Orthotic and Prosthetic Management and Training CPT Codes
CPT code 97760 has been revised for 2018 and now reads “Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies), and/or trunk, initial orthotic(s) encounter, each 15 minutes. CPT code 97760 will now only be used at the initial encounter which is the first visit where you bill 97760 for the time spent assessing the patient, determining the type of orthotic the patient requires, the time to custom fit or custom fabricate the orthosis, fitting of the orthosis to the patient and training the patient in the use of the orthosis. Follow up visits for orthotic management and training will be billed using a new CPT code in 2018 that is described below.
CPT code 97761 has been revised for 2018 and now reads “Prosthetic training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes. CPT code 97761 will now only be used at the initial encounter which is the first visit where you bill 97761 for the time spent in preparation of the stump, strengthening of the remaining musculature, modification of prosthetic fit using stump socks or socket liners, mobility training, use during functional activities as well as skin care and overall conditioning. Follow up visits for prosthetic management and training will be billed using a new CPT code in 2018 that is described below.
CPT code 97762 – Checkout for orthotic/prosthetic use, established patient, each 15 minutes – has been deleted for 2018 and replace with CPT code 97763. The description for 97763 states “Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes.
CPT code 97763 will be used for all subsequent visits when the therapist or assistant is providing orthotic(s) or prosthetic(s) management and training after the therapist billed either 97760 or 97761 for the first visit they provided those interventions.
We have collected information and are making this information available to you. We do our best to gather the information and provide it in a user friendly way. Policies and rulings change frequently. It is difficult to keep up to date. TSHT is not responsible for changes in healthcare rules or laws. Special thanks to Joseph Mathews, DPT, CSCS at Advanced Orthopaedics and Sports Medicine (AOSM) for providing the information about coding and new rules. If there is any error or update that you see as needed, please email Advocacy@tsht.org or firstname.lastname@example.org.
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