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2018-05-01 Medicare Therapy Cap Repealed & 2018 Payment Updates

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On February 9, 2018, the United States Senate and House of Representatives passed H.R. 1892 – “Bipartisan Budget Act of 2018” and President Trump signed the bill into law at approximately 8:30 am ET on February 9, 2018. The bill passed the Senate by a vote of 71-28 and passed the House of Representatives by a vote of 240-186.

This legislation contains several important implications that will have an impact on outpatient therapy services provided by physical therapists, physical therapist assistants, occupational therapists, occupational therapy assistants and speech-language pathologists. This legislation changes the following regarding outpatient therapy services:

  • Annual outpatient therapy cap, exception process, and use of the KX modifier
  • Dollar threshold for the targeted medical review process
  • Payment rates for services provided by a physical therapist assistant or occupational therapy assistant

This webinar will discuss what the therapy cap repeals means for providers of outpatient therapy services, the continued use of the KX modifier, changes to the targeted medical review dollar threshold and payment changes for services provided to Medicare beneficiaries receiving outpatient therapy services by physical therapist assistants and occupational therapy assistants. I will also discuss the 2018 payment changes concerning the most common CPT codes billed by physical and occupational therapy. Did you know there are 7-8 CPT codes that pay better than therapeutic exercise? Are you leaving your hard earned money with the insurance carrier by billing the wrong CPT code?

Educational Objectives:  

  1. Describe and understand the therapy cap and services provided above $2010 in calendar year 2018.
  2.  Define the dollar amount for claims subject to the targeted medical review process
  3. List factors that will determine what claims are selected for the targeted medical review
  4. Discuss payment changes for services provided by a PTA and OTA to Medicare outpatients
  5. Be able to calculate the dollar amount for each visit that will be applied to the annual therapy cap dollar
  6. Recite the payment rate for the top CPT codes billed by physical and occupational therapy
  7. Understand the difference between massage and manual therapy and what code has a higher payment rate 


Rick Gawenda, P.T., graduated in 1991 with a Bachelor of Science in Physical Therapy from Wayne State University, Detroit, Michigan. Mr. Gawenda is currently the President and founder of Gawenda Seminars & Consulting, Inc. He has provided valuable education and consulting to hospitals, rehabilitation agencies, private practices, nursing homes, and his peers in the areas of CPT and ICD-10 coding, billing, documentation, reimbursement, and compliance as it pertains to outpatient therapy services as well as denial management and the appeals process for Medicare denied claims. Mr. Gawenda’s website,, provides a valuable source of information on rehabilitation rules and regulations, coding, documentation, and reimbursement.

Mr. Gawenda is a member of the American Physical Therapy Association (APTA) and Michigan Physical Therapy Association (MPTA). Mr. Gawenda is the Past President of the Section on Health Policy & Administration of the APTA as well as Past President of the Michigan Association of Medical Rehabilitation Program Administrators.

Mr. Gawenda is also the author of “The How-To Manual for Rehab Documentation: A Complete Guide to Increasing Reimbursement and Reducing Denials” and “Coding and Billing For Outpatient Rehab Made Easy: Proper Use of CPT Codes, ICD-9 Codes and Modifiers”.

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