Physical & Occupational Therapy and Speech Language Pathology Caps: Financial Limitation Denials

• PR-119: Benefit maximum for this time period or occurrence has been met

Resolution/Resources
On January 1, 2006, Medicare implemented financial limitations on covered therapy services (therapy caps).  An exception to the therapy cap may be made when a beneficiary requires continued skilled therapy, (in other words, therapy beyond the amount payable under the therapy cap) to achieve his or her prior functional status or maximum expected functional status within a reasonable amount of time. Documentation supporting the medical necessity of those therapy services must be available in the patient's medical record.

Verify whether the patient has exceeded the therapy cap prior to submitting claims to Medicare through the Palmetto GBA eServices tool or Interactive Voice Response (IVR) unit.

Online Verification for Therapy Caps through eServices

• All providers that have an EDI Enrollment Agreement on file may register to use this tool. If you haven’t already registered, please consider doing so.
• Access the introductory article to learn more by selecting the 'Introducing eServices' graphic on the top of any of our contract home pages
• Please Note: Only one provider administrator per EDI Enrollment Agreement/per PTAN/NPI combination performs the registration process. The provider administrator can then grant permission to additional users related to that PTAN/NPI.
• Billing services and clearinghouses should contact their provider clients to gain access to the system
• Specific instructions for accessing therapy cap information through eServices are available in the eServices User Manual (PDF, 7.79 MB) 

If the service qualifies as an exception and may be reimbursed over and above the cap, submit HCPCS modifier KX with the service. Documentation in the patient's medical record must support the use of this modifier. 

HCPCS modifier KX must be submitted in addition to HCPCS modifier GN, GO or GP with therapy services when therapy cap meets all guidelines for an automatic exception. HCPCS modifier KX allows the approved therapy services to be paid, even though they are above the therapy cap financial limits.

• CMS Pub. 100-02, Chapter 15, Section 220.3 (PDF, 1.22 MB)
• CMS Pub. 100-04, Chapter 5, Sections 10.3 and 20 (PDF, 629 KB)