Medicare Therapy Cap 2013 Update

The American Taxpayer Relief Act of 2012 extends the Medicare Part B outpatient therapy cap exceptions process through Dec. 31, 2013.

The annual per-beneficiary therapy cap amounts for 2013 are:

  • $1,900 for occupational therapy (OT), and
  • $1,900 for physical therapy (PT) and speech-language pathology services (SLP) combined.

Exceptions to the therapy cap are allowed for reasonable and necessary therapy services. Per beneficiary, services above $3,700 for PT and SLP services combined and/or $3,700 for OT services are subject to manual medical review (although the the Centers for Medicare & Medicaid Services [CMS] is not precluded from reviewing therapy services below these thresholds.)

CMS is developing a long-term strategy to deal with manual medical review. However, until CMS provides further instructions, Novitas Solutions, the Medicare administrator for Texas, will conduct a complex medical review on all claims suspended for manual medical review of therapy services above the $3,700 threshold. Physicians will receive an Automated Development System (ADS) letter requesting information within a required timeframe for any claims reaching the $3,700 threshold.

See a summary of manual medical review process changes from Novitas.  

CMS has requested that Medicare administrators conduct these manual medical reviews within 10 days. At this time, there is no advance request for an exception process.

Published March 12, 2013 

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