CMS will hold claims over therapy cap exception until Congress acts

by: Roy Edroso Jan 17, 2018

Physician payments

After Congressional inaction allowed the Medicare therapy cap exception to expire on Jan. 1, CMS tells Part B News that it will hold all Medicare claims with the KX modifier “for a short period of time” to make billing those claims easier when, as hoped, Congress reinstates the exception retroactively sometime this year.

As mentioned in the January 15 issue of Part B News, last month Congress failed to reauthorize some features of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that expired Jan. 1, including a 1.0 floor on work geographic practice cost indexes (GPCIs) and the exception to the therapy caps that allowed providers to bill more than the $2,010 cap amount – Medicare’s annual payment allotment for occupational therapy and for physical therapy and speech-language pathology (PBN blog, 8/25/17).

While CMS has no help to offer on the GPCIs at present -- charges based on which will be processed and paid with lower reimbursement for 52 localities – it says it will hold therapy charges with KX (Requirements specified in the medical policy have been met) so that they can be billed if the exception is restored. Claims that exceed the therapy cap that are submitted without the KX modifier will be denied.

Asked to define the “short period of time” they’d hold the claims, CMS said: “We do not have an additional comment on the timing. We will provide more information when available.” Under current law, CMS may not pay electronic claims sooner than 14 calendar days after the date of receipt or 29 days for paper claims but as a rule pays clean claims within 30 days.

Other legislative shortfalls awaiting a fix include add-on payments for ambulance services and home health rural services, payments for low-volume hospitals and payments for Medicare dependent hospitals.

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