Since 2011, NPF has worked with PAN and the NPF Center of Excellence network to address the challenges resulting from the Medicare therapy gap and the Medicare “Improvement Standard” for services such as physical therapy, occupational therapy and speech-language therapy. Effective this year, Medicare beneficiaries can no longer be denied coverage for therapy solely for lack of improvement. For more information, please call NPF’s Helpline at 1-800-4PD-INFO (473-4636) or reference the SSDI & Medicare page on PAN's website.
Additional information from the Parkinson's Action Network regarding Parkinson's and Medicare:
About Therapy Caps & the Exceptions Process
- There is currently a combined $1,920 yearly cap for physical therapy and speech-language therapy, and a separate $1,920 yearly cap for occupational therapy.
- In 2006, Congress created an exceptions process for services deemed medically necessary to serve Medicare beneficiaries who need therapy services beyond the cap. As of now, the exceptions process is available until March 2015.
Communicating the Exceptions Process to Therapists
- If care continues to be medically necessary beyond either $1,920-cap level, the therapist must apply a KX modifier to the therapy code to show the use of the therapy cap exceptions process.
- Documentation, provided by the therapist, must also be detailed and support the medical necessity of continuing therapy. Documentation to support medical necessity also is important when a patient reaches $3,700 in annual spending as Medicare will review each claim above this threshold to determine if care can continue.
- The documentation should indicate why the patient requires continued skilled therapy as the absence of this information may result in Medicare’s decision to deny claims for these services.
For more information about the history of the exceptions process, PAN’s push for a repeal, and what you can do, visit www.parkinsonsaction.org/medicaretherapy.
About The Improvement Standard
- In 2011, the Parkinson's Action Network (PAN) joined a class action lawsuit against the Center for Medicare and Medicaid Services (CMS) over a standard for Medicare coverage that we believed discriminated against people with Parkinson's and other chronic degenerative diseases. (Jimmo v. Sebelius)
- The standard, commonly referred to as the improvement standard, required Medicare beneficiaries to show improvement to continue physical, occupational, and speech-language therapy services, and other skilled services.
- For a degenerative disease like Parkinson's, therapy is not a cure, but it is a treatment option that can improve quality of life and help maintain independence.
- Effective January 7, 2014, Medicare beneficiaries can no longer be denied coverage for physical, occupational, and speech-language therapy and other skilled services solely for lack of improvement.
Communicating the Change to the Improvement Standard to Therapists
- No “improvement standard” is to be applied in determining Medicare coverage for maintenance claims in which skilled care is required.
- The CMS Policy Manual has been updated and therapists are required to adhere to these changes.
For more information about the improvement standard, visit www.parkinsonsaction.org/medicare-improvement-standard.