Medicare Payment Thresholds: A Guide for PT & OT Clinics

Services Contributing to the Therapy Threshold

The therapy threshold encompasses all Part B outpatient therapy services in specific locations. Since 2014, the therapy cap and its associated rules have been applied uniformly to critical access hospitals (CAHs). If a patient's treatment in a CAH surpasses the threshold, the CAH must adhere to the soft cap exceptions process.

Tracking a Patient's Progress

When a new Medicare patient seeks treatment, it's imperative to ascertain if they've availed of any other therapy services during the current benefit period. These services would contribute to the threshold. Therapists can consult the allowable fee schedule to determine the patient's cumulative total toward the therapy threshold. If the patient cannot provide a history of their therapy services, therapists can obtain this data from CMS by liaising with their Medicare contractor.

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Understanding the Therapy Threshold Exceptions Process

Automatic Exceptions (KX Modifier)

The therapy threshold doesn't necessarily limit reimbursement. If a therapist deems continued therapy medically essential, qualifying the patient for a threshold exception, they simply need to append the KX modifier to claims surpassing the threshold. This is termed the automatic exceptions process. By using the KX modifier, therapists confirm that the billed services:

• Are eligible for the threshold exception
• Are both reasonable and necessary
• Necessitate a therapist's expertise and
• Are supported by comprehensive documentation in the patient's medical record

Once a patient's treatment costs reach $3,000 for the current benefit period, these claims might undergo a targeted medical review.