The
following is an explanation of when you can and cannot use an ABN for outpatient
physical and occupational therapy patients.[1]
Therapists
are required to issue an ABN to Medicare patients prior to providing therapy
that is not medically necessary. For example, if a patient has been receiving
PT and has achieved all of her PT goals, but still requests continued PT even
though it is no longer medically necessary, you must issue an ABN prior to
providing the services that will not be covered by Medicare to hold the patient
personally liable for payment.
We
often field questions as to whether an ABN should be used in connection with the
Medicare therapy cap. As background, prior
to 2013, a Medicare beneficiary was financially liable for therapy services
above the cap regardless of whether he or she received an ABN. CMS encouraged providers to alert Medicare
patients to potential financial liability; however, an ABN was not
required. Under these pre-2013 rules, if
a provider submitted a claim that he or she believed qualified for a cap
exception and that claim was denied because the carrier ultimately determined
that the services were not medically necessary, the provider could collect from
the patient regardless of whether an ABN was issued.
This
is no longer the case. Now you must
issue a valid ABN to a patient before providing services above the cap to hold
that patient personally responsible for payment. However, you are faced with a “Catch-22”
situation in that if you believe that services above the cap are medically
necessary, you cannot issue an ABN to the patient because an ABN can only
be used in connection with services that you determine are not medically
necessary. CMS has expressly stated that providers should not issue an ABN to
all Medicare patients who receive services that exceed the cap. In other words, you can no longer issue an
ABN to a patient on a back-up basis to allow collection from the patient if the
carrier determines that the services were not medically necessary and denies
payment.
If
you issue an ABN to a patient for therapy services above the cap because the
services are not medically necessary, a GA modifier should be attached
to the claim. If you did not issue an ABN for these services, the GA modifier
cannot be added to any claim and you cannot collect from the patient.
[1] CMS,
Therapy Caps and Advanced Beneficiary Notice of Noncoverage (ABN), Form
CMS-R-131, FAQs April 2013 (hereinafter, “ABN FAQs”) (http://www.cms.gov/Medicare/Billing/TherapyServices/Downloads/ABN-Noncoverage-FAQ.pdf,
accessed 3/23/15).
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