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Therapy Services Under Part B

After 20 long years, the part B therapy cap has been lifted!

Now, residents are not limited by an annual therapy cap each year. This means that referrals for your long term care residents covered under Medicare Part B can be addressed, and treatment can be provided anytime and as many times as needed during the year. As long as treatments are medically necessary, residents never “run out of money”. This is great news for your residents!

Although the 2018 budget act repeals therapy caps, it still requires providers to continue using a modifier code when submitting claims above $2,100 annually for the purposes of “indicating that such services are medically necessary as justified by appropriate documentation in the medical record involved”. The act also provides CMS with five million dollars a year for nationwide targeted medical reviews of claims that exceed $3,000. However, claims that go above $3,000 will not automatically be subject to targeted medical review. Instead, only a percentage of providers who meet certain criteria will be targeted, such as those who have had a high claims denial percentage or have aberrant billing patterns compared with their peers. It is expected that less than 2 percent of all part B claims will be sent for medical review based on the budget provided for medical review.

Together with the settlement agreement in Jimmo v. Sebelius, your residents will now be able to continue receiving therapy to improve or maintain their current conditions, or to slow or prevent the further deterioration of their conditions, without fear of running out of funds as a barrier to treatment.

Please contact us or a member of your therapy team if you would like an inservice provided to share with your staff the many benefits of Part B therapy to your Long Term Care residents.


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