• A
  • A
  • A
  • (resize font)

LSVT Global Expert Clinicians address Medicare therapy cap

LSVT Global Expert Clinicians have compiled information regarding Medicare reimbursement for LSVT LOUD and LSVT BIG in relation to the new Medicare therapy cap being placed on treatment received within outpatient hospital settings.

As we all know, the world of health insurance is ever changing, and dynamic to say the least.  Recent concerns regarding Medicare reimbursement for LSVT LOUD and LSVT BIG have come to light and we strive to provide our clinicians with insight from the group of LSVT Global Experts who work in the various disciplines and settings our patients come to us from.

Lately, we have received many inquiries and expressions of concern regarding the Medicare therapy cap that is being placed on treatment received within outpatient hospital settings.  Specifically the cap notes that Medicare will cover $1880 per calendar year for combined Speech Language Pathology (SLP) and Physical Therapy (PT) services.  Occupational Therapy (OT) services covered by Medicare are capped at $1880 per calendar year.  First, we encourage clinicians to remember that this cap applies only to Medicare patients at this time, and there are a number of patients who have secondary and tertiary insurances besides Medicare.  Second, while this cap is intimidating at first, one piece of good news is that colleagues working in other outpatient and home care settings have longstanding experience not only dealing with the cap, but also in applying exceptions to the cap, and being approved for additional coverage beyond the cap when deemed medically necessary.   Along with this wealth of experience from colleagues working in non-hospital outpatient settings, we have also consulted expert advice from the American Speech-Language-Hearing Association (ASHA), the American Physical Therapy Association (APTA), and the American Occupational Therapy Association (AOTA) to compile the following information:

The first thing to know is there are two modifiers that clinicians can apply to show specialty care, and also to use when exceptions to the cap are indicated.  These modifiers are used when billing, and on the billing forms there are 3 boxes for modifiers next to the area where the CPT code is documented.  They are as follows:

  • SLP: GN indicates the service is provided under an SLP’s Plan of Care.
  • PT: GP indicates the service provided under an PT’s Plan of Care.
  • OT: GO indicates the service is provided under an OT’s Plan of Care.
  • The modifier KX can be applied by SLP, PT, or OT in the exceptions process to get around the cap.  It should ONLY be used after the $1880 cap has been used, not before.  DO NOT use the modifier if you DO NOT think the therapy is skilled or medically necessary. 

These modifiers indicate that services are reasonable and necessary, and are documented as such in the patient's medical record.  A representative from ASHA with whom we spoke to noted being unaware of any retroactive denials when these modifiers have been applied.  We concur that denials are more likely to occur based on poor documentation versus restrictions from the cap.

There are some additional changes in Medicare to be aware of including therapy claims for a beneficiary on one’s caseload totaling $3700 or more in 2012, may be subject to a special medical review as of October 1st.  The following also applies:

  • Claims for which an exception is not granted will be denied as a benefit category denial, and the beneficiary will be liable.
  • Providers are encouraged-as a courtesy-to give the voluntary advance beneficiary notice (ABN) to patients who require services greater than the $1,880 cap. The ABN alerts them of their possible financial liability.
  • As of October 1, the national provider identifier of the physician or non-physician practitioner certifying the therapy plan of care is required on institutional claims for outpatient therapy services.
  • Although physical therapy and speech-language treatment are combined for triggering the threshold (i.e. PT and SLP services totaling a COMBINED $1880+), medical review is conducted separately by discipline.
  • Providers will be able to request pre-approval for services above $3,700 in 20 day increments. The Medicare Administrative Contractors (MACs) will use the coverage and payment policy requirements currently in the Medicare Benefit Policy manual and any applicable local coverage decisions. They will have 10 business days to respond to a pre-approval request. Requests that do not receive notification within 10 days are automatically approved. Claims submitted above the $3,700 threshold without approval will be stopped, and the standard medical review process will apply.  This standard review allows 45 days for the provider to submit records and 60 days for the MAC to respond. 
  • Applying for pre-approval above the $3700 threshold can be done up to 2 weeks in advance to avoid interruption in care.
  • Speech-language pathologists who are providing Medicare Part B therapy services should be aware of resources and policies provided through their local Medicare Administrative Contractors (MACs). The following link provides a table to include information for each of the 10 Medicare Part B MACs such as:
  1. How to check patient eligibility and therapy dollars towards the Medicare therapy cap.
  2. Where to access policies and guidelines related to the therapy cap, the exceptions process, and the new manual medical review process.

Essentially, this means that SLPs, OTs AND PTs and their respective workplaces need to be aware of how many Medicare dollars have been used/not used. We need to alert patients to the $3700 limit but let them know that if we clearly document in medical records that skilled intervention is needed and functional progress has been made, they MAY receive an additional 20 visits, and all services MAY be covered.

THIS SHOULD NOT BE A PROBLEM FOR LSVT LOUD OR LSVT BIG THERAPISTS obtaining full reimbursement when documenting and billing in an appropriate manner!  LSVT is the only program in our field that has Level I Evidence to support its efficacy in the treatment of voice and speech disorders secondary to idiopathic Parkinson disease and other neural disorders.   LSVT BIG also has support behind its effective use in improving gait and measures on the UPDRS motor score.  These programs also require and facilitate quantitative and qualitative data collection to report all types of gains, especially functional gains, which is great (and essential) for meeting documentation requirements.

Additionally, one major change to Medicare in light of the hospital cap situation is there will be more manual reviews to come.  In most cases patients with PD will qualify for therapy dollars/visits exceeding the cap based on documentation supporting need for skilled intervention, complexity of their conditions, and research supportive of LSVT protocols.   As with any patient, regardless of the insurance they carry, documentation is vital.  When writing reports we need to be clear in stating why the skills of a speech, physical or occupational therapist are indispensable and cannot be delivered by a non-skilled, or non-certified, clinician.  For example, depending on your discipline, one might cite the skills of the certified therapist in modeling, shaping, and driving sensory calibration for speech intelligibility, successful communication in emergency situations—medical and otherwise (for LSVT LOUD Certified Clinicians),  for safe home and community mobility, reducing fall risk (for LSVT BIG Certified Clinicians), reducing burden of care, etc.  When citing a patient’s appropriateness for LSVT LOUD or LSVT BIG in an evaluation report overtly stating “Secondary to patient’s decreased speech intelligibility, postural instability, etc., they are at an increased risk of not being heard in an emergency, falling, etc., making intervention of LSVT LOUD/LSVT BIG with a specially trained and certified clinician medically necessary to maintain their safety, independence, involvement in the community, etc. and thus reduce the burden of care in the future.”  Using this verbiage, in addition to a function-focused plan of care is the strongest proactive approach.

Of general concern are the diagnosis codes and documenting the need for medical necessity when certifying patients for LSVT LOUD and/or LSVT BIG.  As we present across the country, we recognize that some clinicians have success using various codes, and thus we are putting forth the codes we find successful.

On the Medicare certification form we use the Diagnosis Code provided by the physician which is most often Paralysis Atigans/Parkinson disease, ICD-9 Code 332.0.  Secondary Parkinsonism may also be appropriate and is ICD-9 Code 332.1.

Regarding LSVT LOUD, we have found the treatment ICD-9 Codes listed below as successful.  The decision to use one code over another will depend upon your assessment of the patient’s speech and voice functioning and most impaired characteristics. 

  • Dysarthria, 784.51
  • Aphonia, 784.41 
  • Dysphonia, 784.42 

Regarding LSVT BIG, we have found the treatment ICD-9 Codes listed below as successful.  The decision to use one code over another will depend upon your assessment of the patient’s gait, movement, balance, activities of daily living and overall functioning. 

  • Gait/Balance dysfunction - 781.2
  • Falls - V15.88
  • Lack of Coordination - 781.3
  • Deconditioning - 781.99
  • Abnormal posture - 781.92

SLPs--Search "manual medical review" on the website. There is a lot of information posted in a user-friendly manner.

Also,  will lead you to "Requests for Exceptions to the Therapy Threshold: Manual Medical Review Process," which also has helpful information.



For those seeking information on the manual review process the link to this on the CMS website is:

*This is information to the best of our knowledge as of October 1, 2012.  Please check with your individual billing departments for the most up-to-date information.

Latest News

LSVT Global Kicks Off Our 2017 Small Student Grant Competition!

October 21, 2016 3:12 pm MDT

LSVT Global is pleased to provide seed funding to speech, physical and occupational therapy graduate students (including post-doctoral trainees) planning on or completing behavioral treatment studies with neurologically impaired patients. The behavioral treatment does NOT need to be LSVT BIG or LSVT LOUD. Domestic (USA) and international applications are welcome. More Info