Application of Financial Limitations

10.3 - Application of Financial Limitations (Rev. 4214, Issued: 01-25-19, Effective: 01-01-19, Implementation: 02-26-19) (Additions, deletions or changes to the therapy code list are updated via a Recurring Update Notification) Financial limitations on outpatient therapy services, as described above, began for therapy services rendered on or after on January 1, 2006. References and polices relevant to the exceptions process in this chapter apply only when exceptions to therapy caps are in effect. For dates of service before October 1, 2012, limits apply to outpatient Part B therapy services furnished in all settings except outpatient hospitals, including hospital emergency departments. These excluded hospital services are reported on types of bill 12x or 13x, or 85x. Effective for dates of service on or after October 1, 2012, the limits also apply to outpatient Part B therapy services furnished in outpatient hospitals other than CAHs and hospitals in Maryland. During this period, only type of bill 12x claims with a CMS certification number in the CAH range, type of bill 12x and 13x claims with a CMS certification number beginning with the State code for Maryland, and type of bill 85x claims are excluded. Effective for dates of service on or after January 1, 2014, the limits also apply to CAHs. Effective for dates of service on or after January 1, 2016, the limits also apply to hospitals in Maryland. Effective for dates of service on or after January 1, 2018, the KX modifier threshold applies to all the therapy provider types to which the limits applied. Contractors apply the financial limitations or thresholds to the MPFS amount (or the amount charged if it is smaller) for therapy services for each beneficiary. As with any Medicare payment, beneficiaries pay the coinsurance (20 percent) and any deductible that may apply. Medicare will pay the remaining 80 percent of the limit after the deductible is met. These amounts will change each calendar year. Medicare shall apply these financial limitations or KX modifier thresholds in order, according to the dates when the claims were received. When limitations or KX modifier thresholds apply, the Common Working File (CWF) tracks them. Shared system maintainers are not responsible for tracking the dollar amounts of incurred expenses. In processing claims where Medicare is the secondary payer, the shared system takes the lowest secondary payment amount from MSPPAY and sends this amount on to CWF as the amount applied to therapy limits or KX modifier thresholds.