ABN Above $3700 Threshold for Medicare

October 31, 2016
Rick Gawenda

As I speak around the country, I often have people tell me they have Medicare beneficiaries sign an Advance Beneficiary Notice of Noncoverage (ABN) when they exceed $3700 in a calendar year physical and speech therapy combined or a separate $3700 for occupational therapy even though the therapist feels therapy is still medically necessary and requires their unique skills to provide. Actually what the provider is doing is not correct.

Before addressing today’s question, you may want to check out some of my other articles I have written on the use of the ABN for outpatient therapy services:

1. Routine ABNs for Therapy Services

2. Reasons to Use an ABN for Outpatient Therapy Services: Part 1

3. Reasons to Use an ABN for Outpatient Therapy Services: Part 2

The Centers for Medicare and Medicaid Services (CMS) states an “ABN is

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  1. Hello Rick,
    Than you for this article on ABN. Do you have a list of the diagnosis codes (or a resource) that automatically qualify for the KX modifier for PT services beyond the cap amount? Thanks in advance.

    1. There is no list. The list was removed in July 2009. You can use the KX modifier with any ICD-10code(s) as long the ICD-10 code(s) is payable by your Medicare contractor.

  2. unable to access Reasons to use ABN for OP Services: Part 1 – won’t open when click on the link

  3. Is there something we can do for those patients who need therapy above the $3700, we can continue to bill but often times Medicare denies it. Is there a form we can submit to have medicare pay for those who go over? Alternatively can we charge a cash rate above that $3700, since they deny claims?

    1. If you feel therapy is still medically necessary and requires the unique skills of a therapist to provide. you would continue to use the KX modifier. If any claims are denied, whether below or above the cap, you would need to initiate the appeals process.

  4. Hello Rick,
    I have a question regarding a Medicare ABN. If we are seeing a patient that is over his $3700 Medicare cap and the patient wants to continue therapy but there is no medical necessity, can we do one ABN to cover several visits or do we have to do an ABN for each visit?

    1. You would have to list the frequency and duration on the ABN form to cover more than one visit. If therapy is no longer medically necessary, why not DC the patient and have them return for a wellness or prevention program and bill them cash?