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.
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