Starting on January 1, 2017 the limit on incurred expenses for physical therapy is $1,980 and speech-language pathology services combined. There is another limit of $1,980 for occupational services. Deductible and coinsurance amounts paid by the beneficiary for therapy services count toward the amount applied to the limit.
For services furnished during a calendar year that exceed the therapy caps, with an exceptions process in place, providers and practitioners may request an exception on a beneficiary's behalf when those services are reasonable and necessary.
To indicate the medical necessity, the therapy provider or practitioner is required to add a KX modifier to the claim for each applicable service. By using the KX modifier, the provider attests that the services are both (a) reasonable and necessary and (b) that there is documentation of medical necessity in the beneficiary’s medical record.
The therapy caps exceptions process applies an annual manual medical review (MMR) requirements when a beneficiary’s incurred expenses reaches a threshold of $3,700. Each beneficiary’s incurred expenses apply towards the MMR threshold in the same manner as it applies to the therapy caps.