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Medicare Therapy Cap & Use of the ABN

by • March 5, 2018 • 12 Comments

Since passage of the 2018 Bipartisan Budget Act of 2018 that repealed the therapy cap for outpatient therapy services, I have been receiving many questions about the application of the KX modifier for services that exceed either $2010 or $3000 physical therapy and speech therapy combined in 2018 or a separate $2010 or $3000 for occupational therapy. Most of the questions center around should I provide the Medicare beneficiary with an advance beneficiary notice of noncoverage (ABN)  when they exceed either $2010 or $3000 in calendar year 2018?

In this article, I will answer the following questions:

  1. If the therapy cap has been repealed, why do we still have an annual therapy cap dollar threshold and have to use the KX modifier?
  2. If a Medicare beneficiary has exceeded the therapy cap dollar threshold of $2010 in 2018 and I believe therapy is still medically necessary, must I use the KX modifier and bill the Medicare program for those visits and services?
  3. When a Medicare beneficiary reaches the therapy cap dollar threshold of $2010 in calendar year 2018, is an advance beneficiary notice (ABN) required if I feel therapy is still medically necessary and requires the skills of a therapist?
  4. If a Medicare beneficiary has exceeded the targeted medical review dollar threshold of $3000 in 2018 and I believe therapy is still medically necessary, must I use the KX modifier and bill the Medicare program for those visits and services?
  5. When a Medicare beneficiary reaches the targeted medical review dollar threshold of $3000 in calendar year 2018, is an advance beneficiary notice (ABN) required if I feel therapy is still medically necessary and requires the skills of a therapist?
  6. Can we have all Medicare patient’s sign a generic advance beneficiary notice (ABN) on their first visit for outpatient therapy services to protect ourselves from possible lack of payment from the Medicare program?

In addition, if you missed my webinar, Medicare Therapy Cap Repealed & 2018 Payment Updates, you can purchase the playback link and view the webinar as many times as your would like on your computer. The webinar also comes with a handout in pdf format. For additional information on this webinar and to order, click HERE.

For additional frequently asked questions (FAQs) on the ABN, click HERE. For  FAQs on the 2018 therapy cap and therapy cap repeal, click HERE.

Lets now get to the answers!

Question

If the therapy cap has been repealed, why do we still have an annual therapy cap dollar threshold and have to use the KX modifier?

Answer

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12 thoughts on “Medicare Therapy Cap & Use of the ABN”

  1. Elizabeth Bauske says:

    If a patient goes over $3000 in a calendar year, and the chart is audited for the targeted manual review, is the whole episode of care reviewed by the auditer? Just the visits over $2010, or over $3000? Additionally, what if the patient changes clinics at $2500, and then goes over $3000, would the patient’s chart from both clinics be audited, or just where the patient went over $3000?

    1. Rick Gawenda says:

      Dates of service that exceed $3000 in a calendar year would be eligible for the review. If a patient had $2500 worth of therapy services at one clinic and then came to your clinic and exceeded $3000, your dates of service that exceeded $3000 would be eligible for a targeted medical review.

  2. Ken Bariel says:

    unrelated question. can un-licensed person-aide give direct care to Medicare patient under direction of a PT?

    1. Rick Gawenda says:

      If you want to bill for it, no!

  3. david fontana says:

    Hi Rick we have a patient that received care for Lymphedema at a different therapy office and has been receiving PT at our facility since d/c from other facility. She has reached the 2010 cap and we have received the KX claims back from medicare denied because of lack of documentation to support the KX claim? is this the procedure going forward with all claims over the 2010 cap?

    1. Rick Gawenda says:

      Claims exceeding $2010 in calendar year 2018 do not require documentation be sent in with the original claim submission.

  4. Deborah Price says:

    We have had a similar situation to David F. Services provided in Feb 2018 had line item denials from Palmetto V8022 Over limit applied and N435(exceeds limit allowed within time period without supporting documentation). The charges had the appropriate KX modifiers. It seems that Palmetto is denying those services which were over the threshold. What are your thoughts, Rick G?

  5. K. Palazzolo says:

    So Medicare Outpatient Physical Therapy visits are unlimited?

    1. Rick Gawenda says:

      Technically, for most of the past 10 years or so, there has not been a limit since we had the therapy cap exception process available. Now, since the passage of the Bipartisan Budget Act of 2018, there is no therapy cap; however, you will still need to use the KX modifier when providing services above the annual therapy cap dollar threshold.

  6. Tara says:

    Since the caps were repealed… is there still a manual review that takes place after 3000?

    1. Rick Gawenda says:

      Please read my therapy cap FAQs for your answer. https://gawendaseminars.com/faqs/therapy-cap/

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