CMS Provides Clarification Regarding Proper Use of ABNs for Part B Therapy Services

Carl Pucci and Nancy Leveille in Finance & Reimbursement

Daniel E. Ciolek, PT, MS, PMP,Senior Director, Therapy Advocacy at AHCA just received an important clarification via email from CMS regarding when Part B therapy providers should issue Advance Beneficiary Notices (ABN’s) related to services provided above the current $1,920 therapy cap threshold, and what procedure modifiers are appropriate, in situations where there are hard therapy caps, and also in situations where there is a therapy caps exceptions process.

The clarification addresses the following specific questions we asked CMS recently as the current CMS ABN instructions (http://www.cms.gov/Medicare/Billing/TherapyServices/Downloads/ABN-Noncoverage-FAQ.pdf) did not appear to address this possible scenario:

If Congress does not act in time and the hard therapy caps resume on April 1, 2014:

1.    Should providers issue mandatory or voluntary ABNs to beneficiaries that request additional therapy services beyond the $1,920 cap threshold?

2.    If claims with services beyond the $1,920 cap threshold are billed in order to receive a non-covered service denial, which modifier should be used? 

CMS Response:

If the therapy exceptions process isn’t extended, therapists will be required to issue the mandatory Advance Beneficiary Notice of Noncoverage (ABN) for all Medicare-covered therapy services provided above the cap in accordance with §1833(g)(5)(D) of the Social Security Act which extends the limitation of liability provisions to services over the cap that aren’t paid by Medicare.

With a therapy cap exceptions process in place, ABN issuance is not required for medically reasonable and necessary therapy services provided above the cap amount since the claim may be submitted with a –KX modifier for Medicare payment. 

However, if there is no provision for Medicare payment (e.g. hard caps without exceptions), the ABN is statutorily required for services provided above the cap in order to shift financial liability to the beneficiary.

Therapists must also continue to issue the ABN for therapy services that aren’t medically reasonable and necessary regardless of therapy caps. 

When an ABN is issued, the –GA modifier is applied to the claim.

The –GY modifier is used for services that are statutorily excluded or not a Medicare benefit and never covered by Medicare. For example, once a beneficiary has reached his goals and is discharged from therapy, he may wish to continue on a personal training program with his therapist and pay out-of-pocket. In this case, if the beneficiary wants a Medicare claim filed for the personal training services, the –GY would be applied to the claim. 

AHCA Comment:

Proper compliance with Medicare ABN requirements is essential to assure that both beneficiary and provider financial rights are protected.  If the therapy caps exceptions process extension is not enacted by March 31, then SNF providers should be prepared to comply with the ABN requirement clarification described above for services furnished above the $1,920 therapy caps threshold.

Helpful Reference Links:

Therapy Caps and ABN FAQ

Advance Beneficiary Notice of Noncoverage (ABN) Booklet

Fee For Service Advance Beneficiary Notice of Noncoverage web page

ABN Form and Instructions

Medicare Claims Processing Manual ABN Instructions

AHCA Therapy Caps Web Page

 

  NYSHFA CONTACTS: Carl J. Pucci
Director, Finance & Reimbursement
518-462-4800 x36
  Nancy Leveille, RN, MS
Sr. Director, Member Operational Support
518-462-4800 x20