Routine ABN’s for Therapy Services

May 25, 2015
Rick Gawenda

I am often asked can we have all of our Medicare patient’s sign an advance beneficiary notice (ABN) on their initial appointment to protect us in case our Medicare Administrative Contractor (MAC) denies any of our services as not medically necessary? I am also asked that once a Medicare beneficiary reaches the annual therapy cap dollar threshold ($1940 for physical therapy and speech therapy combined and a separate $1940 for occupational therapy in calendar year 2015), can I have the Medicare beneficiary sign an ABN even though I feel the therapy services are medically necessary to protect us in the event my Medicare contractor denies the services as not medically necessary? Lastly, I am asked that once a patient exceeds $3700 in covered PT and SLP services combined or a separate $3700 in covered OT services in a calendar year, can I have the Medicare beneficiary sign an ABN even though I feel the therapy services are medically necessary to protect us in the event my Medicare contractor denies the services as not medically necessary?

The Centers for Medicare and Medicaid Services (CMS) addresses the use of “routine ABN’s” and “generic ABN’s”. Regarding the “routine” use of ABN’s on a patient’s first visit to therapy, CMS states

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  1. I understand that if therapy services are considered medically necessary by the provider an ABN form is not mandatory, but what if Medicare comes back and says the services are not mandatory even though the provider thinks they are? should an ABN form be issued just in case and if so do we list all of the services that could be provided?

    1. No. If denied, you would have to go through the appeal process with your Medicare contractor.

      1. so if we don’t sign an ABN form and we do an appeal and we get denied (even though the PT thinks it is medically necessary), then we wouldn’t be allowed to bill the patient cause the ABN form has to be filled out prior to treatment, correct? We actually had a patient that the PT as well as the patient’s doctor felt that therapy was needed (patient had had surgery), insurance denied saying it was not medically necessary and would not pay. If this would have been a medicare patient, an ABN would not have been mandatory, however by the time it was over the clinic would have had to eat the bill because we could not bill the patient correct? So where does the ABN form come into play here?

  2. I have patient’s with secondary insurances that will pick up payment after Medicare has exhausted. I do not need the KX modifier because i know that they will pay as long as Medicare shows Patient liability for that amount. Medicare will not show patient liability on their eobs unless there is an ABN on file. Is this a true statement ? how else can i get Medicare to show patient liability so that the insurance will pick up the balances once Medicare is exhausted

    1. If you think that therapy is medically necessary for the secondary to pay for it, shouldn’t it also then be medically necessary for the Medicare program to pay for it? By the way, that answer is yes, so you would then still submit to Medicare if you think therapy is still medically necessary and requires the skills of a therapist to provide and if above the therapy cap, append the KX modifier.

  3. just to clarify…if the patient exceeds their $1960 cap, we append KX modifier so long as therapist feels servcies are still medically necessary. if/when patient then exceeds the $3700 threshold, continue with KX modifier – no ABN, so long as therapist continues to feel services are medically necessary. only do ABN if therapist does not support the physicians request to continue services based on lack of medical necessity – correct? thanks, Kim

    1. You are correct in what you state. If the therapist believe therapy is still medically necessary, you would use the KX modifier for services provided above the annual therapy cap dollar threshold.

  4. Similar but not the same- Is a NOMNC necessary in an SNF for Part B services when ending as a way to notify that a pt can appeal?

  5. I just need some clarification on a couple of things regardless if patient has met the Medicare cap or not. If the therapist feels that the patient is no longer medically necessary and the patient still wants to continue with therapy that’s when an ABN would be signed correct? also after the patient has signed the ABN and they select option 1 to bill Medicare would we continue billing only the “KX” modifier or would we use both the “KX” and “GA” modifier? Or would we bill only the “GA” modifier?