New Medicare Limits Will Affect Lymphedema Patients

By: Debra Daugherty, OTR, CLT-LANA
Texas Health Presbyterian Hospital of Dallas, Dallas, TX

What is the “therapy cap?”
If you are over 65 then you have probably already heard about the new financial “cap” that Medicare has initiated for outpatient rehabilitation. The statutory Medicare Part B outpatient therapy cap places an annual $3,700 limit on occupational therapy services and an additional $3,700 limit on physical therapy and speech therapy services.

This particular statute does not apply to any therapy you might receive as a hospital inpatient (Medicare A). It only applies to Medicare B, which generally covers outpatient services. It does not place any limits on visits to your doctor’s office, but it does place severe limits on any rehabilitation you may get, including lymphedema treatment. In Texas, the cap applies to private clinics, hospital-based outpatient clinics, home health agencies, skilled nursing facilities (SNF) part B, ORF’s CORF’s, etc. In other words, any rehabilitation service that files claims to Medicare Part B will be affected by this cap.

The cap is not limited to one diagnosis, but to any and all outpatient rehabilitation received in 2013. One bad fall or one car accident may cause you to run through all your allotted therapy dollars rather quickly. Then you and your therapist will have to go through an appeals process. The cap will be a problem for many seniors, and it will be particularly hard on those with chronic conditions such as lymphedema.

How does it work?
The process is convoluted. There is an initial cap of $1,900. After that, the therapist must have documented evidence to support the necessity for continued intervention. Once the cap has reached $3,700, Medicare will initiate a manual medical review to decide if they think the service is medically necessary. Unfortunately, this manual medical review process (MMRP) is a work in progress. No one, including your therapist, knows how involved it will be or how long it will take. But your therapist will probably have to interrupt your therapy until a determination is made.

How will it affect me?
The average lymphedema patient should be able to get at least one full course of MLD/CDT treatment under this cap. However, those with medical complications may run into problems. If you have bilateral lymphedema, wounds, severe fibrosis or other medical issues, your treatment will probably take longer. Also, you should be concerned about using all of your therapy on one problem and having no money allotted for anything that might occur in several months. One fortunate thing is that both occupational therapists and physical therapists treat lymphedema and each profession has separate filing caps. Thus you could conceivably receive $3,700 of OT treatments and then get $3,700 of PT treatments.  

What can I do?
First, you need to start keeping track of any rehabilitation services you receive in 2013.

    1. Check your “Medicare Summary Notice” (MSN) that you receive every few months. It lists the services you have received and the amount billed. Hold on to these notices.
    2. Keep track of any rehabilitation you have had for the year, including the names of the hospitals, home health agencies and outpatient clinics you have used. Be sure to write down if you received occupational therapy, physical therapy or speech therapy.
    3. Visit to track your claims.
    4. You can also call Medicare at 1-800-633-4227. TTY users should call 1-877-486-2048

Is this permanent?
There has already been movement to repeal the cap. On February 14, the “Medicare Access to Rehabilitation
Services Act” (S 367 and HR 713) was reintroduced and is under consideration. It would be a helpful for you to let your congressional representative know what you think about these bills, whether you are for the cap or for its repeal. A good place to find out who your representatives are is All you need to enter is your nine digit zip code and it will tell you who your representatives are, along with how to get in touch with them.

DSDaugherty [at]