Medicare Updates 2019

1 -G-codes

Functional Limitation Reporting , a.k.a. G-Codes, will not be required for therapy Part B visits provided on or after 1/1/19

2- Therapy Cap

  • The cap has been gone for 1 year and is not coming back! But…..
  • The Final Rule requires the use of the KX modifier to all therapy services that “would have exceeded the previous therapy cap amounts”
  • The Therapy Cap has now become the KX Modifier Threshold
  • KX modifier is needed on Part B claims for services over the “threshold” in order for the services to be paid by Medicare
  • New “threshold” for 2019 is $2040 for OT, $2040 for PT and Speech combined (up 1.5% from last years amount)
  • Payment will be denied of no KX once threshold is hit

3- Manual Medical Review

  • Threshold continues at the same amount of $3000 until 2028
  • Review is not automatic. CMS is limiting reviews to “outliers” and those with questionable practice patterns

Coming in 2020

 Reduction of Payment for Part B Services Provided by Assistants (PTA, COTA, OTA)

  • All therapy services on or after 1/1/20 provided in whole or in part by an Assistant will need to be billed using the new payment modifiers
    • New PTA Payment Modifier: CQ
    • New OTA Payment Modifier: CO
  • All therapy services on or after 1/1/2022 provided in whole or in part by an Assistant will have a payment reduction of 15%  applied

What does provided in whole or in part mean?

CMS is defining in whole or in part  as provision of  more than 10% of a therapy service by an assistant.  The Final Rule states that specifics to this point will be addressed in the 2020 Proposed and Final Rules. {This is an improvement from the Proposed Rule which defined in whole or in part as “any minute!”} By using the payment modifiers in 2020, CMS will have 2 years of data collection to assess potential revisions to the requirements.