Skip to comments.Medicare Part B Outpatient Therapy Caps: Effective October 1st, 2012
Posted on 09/18/2012 6:13:58 AM PDT by NoobRep
The statutory Medicare Part B outpatient therapy cap for Occupational Therapy (OT) is $1,880 for 2012, and the combined cap for Physical Therapy (PT) and Speech-Language Pathology Services (SLP) is also $1,880 for 2012. This is an annual per beneficiary therapy cap amount determined for each calendar year. Medicare allowable charges, which includes both Medicare payments to providers and beneficiary coinsurance, are counted toward the therapy cap. In outpatient settings, Medicare will pay for 80 percent of allowable charges and the beneficiary is responsible for the remaining 20 percent of the amount.
The therapy cap applies to all Part B outpatient therapy settings and providers including: » private practices, » skilled nursing facilities, » home health agencies, » outpatient rehabilitation facilities, and » comprehensive outpatient rehabilitation facilities.
Beginning this year, the therapy cap will also apply to therapy services furnished in hospital outpatient departments until December 31, 2012. Before 2012, therapy provided in hospital outpatient departments did not count towards the therapy cap.
But, what they don't tell you is "watch the other hand"!
I can elaborate.
Like any of the other names Obama chooses for his mandates, the irony in “Middle Class Tax Relief and Jobs Creation Act” is so thick you can cut it with a chainsaw.
The government is broke and the people can’t afford to pay more. Every spending cut is going to gore someone’s ox. It really doesn’t matter though, because once we roll off the fiscal cliff and hit bottom, all benefits will be cut.
Most of the clientele for where my mom works relies on their Medicare to cover these expenses. Luckily she’s near retirement because IMO they will simply go out of business.
There have been caps for Medicare Part B OP therapy for a long time though the amounts have changed and PT, OT and SP have not been exempt.
What a facility will charge for an OP visit may be $650 but what is allowable and reimbursed under Medicare is significantly less.
The total reimbursed amount will vary depending on the CPT-4 coding that the therapist use.
There are new rules and regulations in healthcare that come out every fiscal year. I’ve worked in rehab management for over 20 years and we go through billing and coding changes every September CMS releases their new coding and diagnosis
guidelines and how billings can be coded etc. Every department in the hospital who charges patients has to go
through this process. Some years suck because of the changes, and others are not so bad.
And just a fun little fact, the reason that PT and ST are lumped together is that when they originally came out with the ruling for the caps (years ago),
that when CMS was typing up the ruling, they forgot the comma and would not make a correction to separate the two
There is a lot we can hang on Obama’s head, but this is not one of them
If Bush did this the DU would have melted down...
That is not what the gov site says. It says with Balanced Budget Act of 1997, caps for other services were added but not for Outpatient centers.
I know there are new regulations every year. My wife is a coding specialist.
But, the elephant in the room is this: our government-paid health care is based on a prosperity model where we can afford to pay for whatever people want (OT for a retired person???). When the economy could support it, this was acceptable; but now we can’t afford it. We simply do not have the money.
As I said, its too hard to make cuts because someone’s ox will always be gored, so lets just keep going until the whole system crashes then we can do 100% cuts across the board.
If a single outpatient visit involving speech therapy and rehab costs $650 that’s criminal. It’s highway robbery and the government (that is, taxpayers) shouldn’t be paying it.
Don’t get too worked up over what is billed. The government barely pays for the cost of services. In a number of instances, it doesn’t even do that.
That’s why it’s such a hoot when you hear some government figures saying something like, “Health care providers will simply have to do with less profits.” What profits?
Most hospitals are working on a razor thin margin as it is.
Just ask that political figure who is paying the bills of the illegal alien and the indigent? Say what?????
Gotta replace those three year old executive chairs in the administration wing....
That’s a correct assumption if the OT was working at an Workman’s Comp/Occupational Health clinic or as an workplace ergonomics specialist.
If the retired person were to have a stroke or a major orthopaedic event, they’d want an OT to help them with relearn
or learn compensatory strategies for their ADLs (activities of daily living) such as dressing, showering, eating, toileting etc. It’s tough for anyone to learn to live with only one side of their body working properly, it’s even harder for the geriatric population.
The only area of Part B which these caps do not apply is in the facilities that are classified as Critical Access which are found in rural areas.
There are many services provided that the government payors don’t come close to covering the actual cost of providing care.
I love when people think hospitals (profit or not for profit) are making money hand over fist. The largest realized profit margin I’ve ever seen in the organizations I’ve worked for was 5.1%
Tens of millions of dollars each and every year are written off as bad debt due to illegals, and this is per hospital in a 5 hospital system in Denver.
I was in PT and OT after kneee surgery. It was ridiculous. After the first session, I had learned everything I needed. After that, it was just a $40 co-pay three times a week so I could go do my own exercises in their facility with a “range of motion” check every few sessions. They wanted me to do it for 6-8 weeks (which coincided with my limits of benefits by a strange coincidence.)
Following a neck injury, it was the same thing, different clinic.
If you have a stroke and lose half your body, I think its a worthwhile expenditure from the people’s treasury. But, most of the people I saw at the PT/OT clinic were healthy enough to do stretches at home without expensive supervision. We have to stop this “one size fits all” approach to benefits. The needs of the stroke victim do not justify $10,000 worth of PT/OT for a knee surgery.
But, by all means. Let’s keep the spending going. It will end eventually one way or the other, but if we run out of money, then your stroke victim will not get any help because we spent all the money on the 30 year old Medicaid recipient who weighs 400 pounds and had her knees collapse and is now on SSI getting treatment for everything under the sun.
Who comes up with these names?
That’s great you were able to do your HEP and obtain the benefits you needed and your therapist should’ve discharged you when you demonstrated independence, and not when you benefit limits were reached.
You are the rare bird that actual listened and did what was asked of you. Not every clinic or every therapist is ethical, and that is one of the major reasons why the cap
for medicare was put in place.
Who could be against patriotism? I call ‘the Patriot Act’ the “Patriotism is the last refuge of a scoundrel Act”.
The ‘Affordable Care and Patient Protection Act’ is obviously the “Death-panel Act”.
The ‘Middle Class tax Relief and Job Creation Act’ is now dubbed the “Target tax breaks for favored constituents and crony capitalism Act”.
I swear to God that someday we shall see the “Motherhood and Apple Pie for America Act” or some such overinflated verbal garbage meant to obscure and distract.
See post #20.
People have a very skewed view of how hospitals operate.
Ask them how much the government pays for that new cat scan machine? How much does the government pay for administrative services, the business office, collections, that replacement wing ordered by the government due to new earthquake standards.
In fact the government does provide some funds for certain projects, but the windows are narrow, and the funds are nowhere near payments in full.
What you’ll get is some response talking about $5.00 dollars per aspirin tablet.
I wonder how many people could run their household reasonably if the government demanded they spend $10,000 dollars within six months, or loose the $2,500 dollars the government was willing to pay to help, otherwise you’d have to pay it all, and possibly face fines as well.
That’s what hospitals face all the time.
People hear the word hospital and think big oil. These are costs that are out of their hands, and they think they’re being gamed. Sometimes they may be, but generally they aren’t.
You're right. It's funny because this was a classic Russian cold war tactic - to name something the opposite of what it was... so the 'Freedom League' would be a group that worked against freedom... Weird.
Oh my a voice of knowledgeable reason:)!!
Let’s not forget the cost of government regulations which do nothing to help the clinical aspect of patient care (HIPAA is coming to mind)
Or how about the cost to the hospital of subjecting themselves to CMS audits in order to receive the monies from the government? This of course leads to more ridiculous and nonsensical changes to clinical delivery, or risk losing all back payments, because the fat and old auditor had a hair on that day.
I believe people think that the US healthcare system has been run as a capitalist system. It’s been socialized for as long as I’ve been in the field.
There is fraud and abuse within the healthcare system but is significantly less than the fraud and abuse of many systems and definitely less than our government.
It’s a mathematical impossibility for a society to provide free health care when the average individual’s aggregate lifetime healthcare costs outstrip the average individual’s aggregate lifetime earnings. It really is that simple.
Re: OT for a retired person?
OT deals w/adaptive skills for daily living. Retired or not, folks need to get around, reach for and retrieve things, wash, dress and feed themselves, use a bathroom. In my area, OT also may deal with helping patients after joint replacements and vascular surgery after their PT sessions are ended. No patient has the ability to demand PT/OT, although they can ask. It is solely at the discretion of the MD, who, in turn, is subject to the protocols of the institution.
My husband is a medical massage therapist in private practice. He sees these people, often on referral, after their PT/OT ends. There is a cap on number of sessions allowed per patient/per incident. PTs and OTs are subject to restrictions by the referring MD, such as limited area to be treated and limited time per session. These restrictions have been in place for a long time. The PTs themselves are fine with someone seeking private sessions.
The major hospital for our area charges $350/massage done on premises and the patient is responsible for the $60 copay. This makes a $50 private massage session affordable. However, the hospital-based MTs are not paid $350 or even $50.
Many PTs here are in private practice and can accept insurance. Massage is not covered, so I don’t know what the insurance pays. However, MTs must code the session if there is a cafeteria allotment and reimbursement on the employer-provided insurance. Only one or two codes are acceptable for reimbursement and they do change yearly. These sorts of insurance allotments are usually limited to a set amount per year.
Which, of course, will be a bill providing free or discounted abortions to the 'less fortunate', paid for by a tax on sugary desserts.
Just a bit more food for thought:)
HIPAA on it’s own as patient privacy appears okay. Anyone outside of front line healthcare workers foresee the impact it would have on law enforcement? How many FTEs needed to be added to an organization just to be compliant?
Don’t accidentally click on the wrong Jim Smith in the system if you don’t have the proper security clearance. It will more than likely lead to disciplinary action.
But it has saved the high profile/famous patients info from
getting to the public.
And on your last one, been there, done that, pulled my hair out along with the biller/coder trying to figure out how to interpret CMS’ new codes and how to run it through without it getting flagged and/or denied.
More good examples there...
Here’s another. The government cuts the number of patients an R. N. can be responsible for at one time. All of a sudden a nurse that could cover six patients, now can only cover four.
FTEs must then be raised by 50%, just to cover the same number of patients. Does the government then raise the rates it will pay for services on that floor? Of course not.
Then folks laugh, when hospitals claim that government regulations are killing them.
And the government itself, damns the hospital for not controlling it’s costs.
Everyone keeps explaining to me how wonderful and necessary OT/PT is, but no one is explaining how we can pay for it. In medicine, there is something called Triage. You deal with the life-threatening stuff first. Nothing in PT/OT is life-threatening. Neither is ED treatment or a host of other things that have been piled on top of Medicare over the years because we had the prosperity to pay for it.
Those days are gone. The workforce is shrinking and the non-productive portion of society is growing. People expect health care in their final years that exceeds their total lifetime income and no one is allowed to question it. Then, they shelter their wealth through clever trusts to keep Medicare from recouping any of the losses. How do we expect to save this country with that level of selfishness coded into our system?
You are buying into the collectivism meme.
If medical care was simply available on an out-of-pocket, fee-for-service basis, we might have a multi-tiered system, where the advanced tech/medicines were available to those who could afford them. With privately available insurance, more people might have access. If religious charities were not being coerced to give up their ideals, they would still be a source of care for the less fortunate.
We are giving control to a single-payer and the decisions are now collective. So: no PT/OT or dysfunction treatment to anyone because they aren’t *vital*. As decided by whom? The same geniuses who want to collectivize medicine are responsible for the shrinking workforce through outsourcing, aborting the next generation of workers, not allowing private capitalization for new industries and dumbing down the general academic and technological training available by demanding that everyone get an A and be certified in the name of fairness, while limiting the number of places available for that same training because education is also being centrally controlled.
Rehabilitative medicine serves a collective good: people become functional again and therefore become contributing members of society. Resources are not tied up providing maintenance care to the injured. How would it serve some greater good to just let people remain immobile and dependent? Of course, you could argue that jobs are created for attendants. Immobile, depressed, dependent people die sooner of complications. Is this a greater good, as it decreases the pool of people competing for scarce medical resources? It is just euthanasia, via triage. Triage is relevant in emergency situations and on the battlefield. It is criminal when applied to the general population in non-emergency situations.
We have had rehabilitative medicine for a long time. PT evolved out of treating bayonet wounds from WWI. OT split off from PT after the polio epidemic, when people who were now mobile needed to relearn how to take care of themselves.
As for ED treatment:every culture has tons of folk medicine aimed at restoring sexual potency. A simple drug is cheaper and more effective, w/less side effects than rhino horn and more socially acceptable than sleeping with multiple virgins. People denied sexual function become psychologically warped. But, so what, as long as the collective is not paying for it.
If we stop the idea of a limited medical resource pie paid from a pool coerced from everyone and administered by bureaucrats, the medical advancements would either be utilized or not by those who decided for themselves what they needed. It is the same people who promised everyone the best of medical care who are forcing them now to pay more for it in the form of taxes.
As an MT, my husband will likely be out of practice if his modality becomes subsumed under some National Health. The untrained administrators will decide who gets treatment and also what that treatment will be, how long it will be provided and what pittance the provider will be allowed. When all of medicine becomes unionized, that power will be complicated by the providers simply refusing to practice.
Eventually, no one will receive anything much in the way of care, as no one will be left to provide it. The *right* to medical care will be another moot right and be replaced by the privilege of care for the politically correct. This assumes there will be providers, technology and pharmaceuticals available even to them. Right now, we have governmentally-facilitated shortages in all those areas.
We had a wonderful medical system that advanced human well-being and was available to all. It was possible to provide the very best even to the indigent as some providers were subsidized by private means to do so via charities, usually religious ones. Now, having decided that there must be some mythical equality of care paid for collectively and administered by non-competent political appointees, we are losing one modality, one treatment, one drug at a time.
I wonder how people will feel when the treatment they need is not available when they need it? I already hear people moaning that home health care for the elderly or the disabled isn’t free. It seems that the collective is in favor of slavery and tyranny as long as they personally pay nothing. The truth is, of course, they pay as much as can be extorted from them, while receiving a minimum.
Analogous to this is that veterinary medicine is dependent upon human medical technology and treatments. Limit the entire field as is being accomplished and there will be no treatment for any animal, from pets to food animals.
Now, just which ideology is in favor of those outcomes? The one that triumphed in the same places that decided to use *barefoot doctors*.
Blaming the elderly, who were promised medical care in exchange for a lifetime of taxes, is just a blame-game. Retirees pay for Medicare, pay for supplemental insurance policies and pay co-pays. It is a goal of the controllers to end all inheritance. Anyone who can protect their life savings, while still paying for their insurance and their care, is not necessarily selfish. They are trying to insure that they will be left with something on which to live, as well as to pass on to their descendants.
It is the system as it is being forced upon us that creates all of these situations.