2018 guide­lines for Medi­care phys­i­cal ther­apy pa­tients

The Mercury (Pottstown, PA) - - HEALTH - By Dr. John R. Mishock

What is the Medi­care Phys­i­cal Ther­apy Cap?

In 1997, as part of the Bal­anced Bud­get Act, a $1,500 cap ($2,010 for 2018) on out­pa­tient phys­i­cal ther­apy and oc­cu­pa­tional ther­apy ser­vices was im­posed. Mean­ing the maximum paid by Medi­care for ther­apy ser­vices would be $1,500. Each year af­ter this, Congress would pass a mora­to­rium to al­low Medi­care pa­tients to ex­tend past the $1,500 as long as the provider could prove med­i­cal ne­ces­sity.

Cur­rently, is there a Medi­care hard Cap on Phys­i­cal Ther­apy? No

As of Jan­uary 1, 2018, Congress abol­ished the hard cap on phys­i­cal ther­apy and oc­cu­pa­tional ther­apy ben­e­fits.

Are there lim­its on phys­i­cal ther­apy ser­vices for

Medi­care pa­tients? No Medi­care ben­e­fi­cia­ries are el­i­gi­ble for phys­i­cal ther­apy ser­vices in­def­i­nitely with no mon­e­tary lim­i­ta­tion as long as their health care provider (physi­cian, physi­cian as­sis­tant, nurse prac­ti­tioner or den­tist) con­firms their need for phys­i­cal ther­apy.

If the Cap was abol­ished why is there $2,010 ther­apy cap for 2018?

If a Medi­care re­cip­i­ent ex­ceeds $2,010 in ther­apy pay­ments the provider will need to use a KX mod­i­fier for attes­ta­tion that the ser­vices are med­i­cally nec­es­sary. Medi­care will still pay claims be­yond this point as long as the provider jus­ti­fies med­i­cal ne­ces­sity.

What hap­pens if I ex­ceed $3,000 in ther­apy ser­vices?

Prior to 2018, if a Medi­care pa­tient ex­ceeded $3,700 it would trig­ger an au­to­matic re­view by Medi­care of the provider to de­ter­mine if the treat­ment was med­i­cally nec­es­sary. Now, if the an­nual claims are greater than $3,000 in ther­apy ser­vices it will not au­to­mat­i­cally trig­ger a med­i­cal re­view. A Medi­care re­view will be se­lec­tively placed on a small per­cent­age of providers who meet cer­tain cri­te­ria such as; those who have had high claims de­nied, or those who have aber­rant billing pat­terns com­pared with their peers.

Will I lose Medi­care cov­er­age if I have a chronic ill­ness? No Un­der a 2013 court set­tle­ment, pa­tients will not lose cov­er­age sim­ply be­cause they have a chronic disease that is not im­prov­ing. As long as your health care provider deems the phys­i­cal ther­apy treat­ment med­i­cally nec­es­sary, phys­i­cal ther­apy ser­vices will be paid for to main­tain the pa­tient’s con­di­tion, pre­vent or slow de­cline. There is no ar­bi­trary limit on how much Medi­care will pay for phys­i­cal ther­apy ser­vices.

If pain is lim­it­ing you from do­ing the ac­tiv­i­ties you en­joy, give Mishock Phys­i­cal Ther­apy a call for a Free Phone Con­sul­ta­tion at (610)327-2600 or email your ques­tions to mishockpt@com­cast.net. We Can Help! Visit our web­site to read more phys­i­cal ther­apy re­lated ar­ti­cles, learn more about our treat­ment phi­los­o­phy, our phys­i­cal ther­apy staff, and our 6 con­ve­nient lo­ca­tions in Gil­bertsville, Skippack, Barto, Phoenixville, Lim­er­ick, and Stowe at www. mishockpt.com.

Our mis­sion is to ex­ceed the ex­pec­ta­tions of our pa­tients by pro­vid­ing ex­cel­lence in care and ser­vice. We are here to serve you!

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