CMS addresses payment cap moratorium, evaluation period for therapy services

Healthcare Financial Management, March, 2004

CMS has published a one-time notification regarding the renewed moratorium on physical therapy, occupational therapy, and speech-language pathology service payment caps for claims received from December 8, 2003, through December 31, 2005. The notice implements a provision of the Medicare Drug, Improvement, and Modernization Act of 2003. The separate payment caps of $1,590 for combined outpatient physical therapy and speech-language pathology services, and for outpatient occupational therapy services remain in place for claims received from September 1, 2003, through December 7, 2003, for services provided during this time.

CMS also clarified the time period within which a physician must evaluate a patient undergoing such therapy services. According to a CMS transmittal, a Medicare beneficiary undergoing such therapy must see a physician or nonphysician practitioner within 60 days after the therapy begins and every 30 days, thereafter. The 60-day period begins with the therapist's initial encounter with the patient. The initial encounter should occur in a timely manner after the physician's referral, CMS said. In addition, the timing of recertification and visit requirements should coincide.

To read Transmittal 40 on therapy caps, go to www.cms.hhs.gov/manuals/pm_trans/R40OTN.pdf. To read Transmittal 5 on the time period for therapy, go to www.cms.hhs.gov/manuals/pm_trans/ RSBP.pdf.