Medicare has announced that the therapy cap amounts for 2013 will be $1,900.00 for Occupational Therapy (OT) and a separate $1,900.00 cap for Physical Therapy (PT) and Speech Language Therapy (SLP) combined. There is also a $3,700.00 threshold for OT with a separate $3,700.00 threshold for PT/SLP combined. Services that will apply to the $1,900.00 cap and $3,700.00 threshold are all Part B outpatient therapy services and the following Part A providers:

Therapy Cap

Medicare Therapy Cap/Threshold policy 2013

  • Part B skilled nursing facilities
  • Home health agencies (type of bill 34X)
  • Outpatient rehabilitation facilities (ORF)
  • Rehabilitation agencies (comprehensive outpatient rehabilitation facilities [CORF])
  • Hospital outpatient departments (HOPDs)

Unlike in 2012 there will not be a preapproval process in 2013 for services that will go beyond the $3,700.00 threshold. Providers need to bill their services and if they go beyond the $3,700.00 threshold Medicare will suspend the claim and send an additional development request (ADR) to the provider. The provider will then need to submit the documentation to demonstrate the medical necessity of the services. Medicare will review this documentation and make a decision on payment or denial of the claim. If a patient is referred for therapy for a new episode of care and has already reached the threshold, Medicare will cover the evaluation charge but may send an ADR for documentation.