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CY2018 Final Rule & What Outpatient Providers Need to Know


At Mid South, we do our best as contract therapy providers to stay informed about therapy provider news. Although we have Strategic Partners and facilities from a wide array of clinical settings, there have been recent updates that we’d like to outline impacting outpatient rehab providers.

On November 2, 2017, CMS released the final rule for CY2018 for services paid under the Physician Fee Schedule along with the update for therapy codes. These UPDATES can be found below along with what the changes mean for providers.

  • Therapy Cap: The 2018 therapy cap amount for Speech-Language Pathology and Physical Therapy services together is: $2010. The 2018 therapy cap amount for Occupational Therapy is: $2010. The manual medical review amount stays the same at $3700. There is a current Medicare extenders package in the House that could permanently eliminate the therapy caps exceptions process. This said, the exceptions process is set to expire on December 31, 2017 without further action by Congress.

  • What this means for providers: Without action, beneficiaries will be 100% liable for any services provided above the $2010. We will keep you posted on this process.

  • Cognitive Skills (97532): This code (97532) will be deleted as of January 1, 2018. CPT 97127 has been created; however, CMS has made it an invalid code for billing Medicare. CMS will instead use G0515 - which will mirror 97532.

  • What this means for providers: When billing Medicare, use G0515 and check with other payers to see if they will be using 97127 or G0515. The new Medicare code G0515 will be a "sometimes" therapy code so it will require the GN, GO, and/or GP modifier. CMS will review the data collected on this code to determine an appropriate RVU for 97127.

  • Orthotic / Prosthetic Management and Training: The CPT codes for these services have been revised. CPT code 97760 should only be used for the Initial Orthotic visit. CPT code 97761 should be used only for the Initial Prosthetic visit. Follow up visits for orthotic management and training will be billed using a new CPT code in 2018. CPT code 97762 has been deleted for 2018 and replaced with 97763, which is used for both Orthotic and Prosthetic subsequent encounters including discharges.

  • What this means for providers: There will be two codes for orthotic/prosthetic management and training 97760 for the first visit with all subsequent visits billed using 97763.

  • Work Relative Value Units (RVU): The RVUs for 8 codes: 97112, 97113, 97116, 97533, 97537, 97542, 97760 and 97761 increased.

  • What this means for providers: These RVU increases may result in a slight increase in reimbursement.

If you have any further questions or are unsure about any of the above information, feel free to contact our team. We are here to help, clarify, and continue to serve as your resource for news and insights in the therapy provider industry.


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