CMS has posted updated FAQ for Therapy ABNs, providing the keys to understanding when an ABN is needed in the post-therapy cap era. Providers have anticipated this since the therapy caps were permanently eliminated in the Bipartisan Budget Act of 2018, passed in February. Under section §1833(g)(8) the therapy provider is financially liable for the cost of therapy services provided to a beneficiary above the threshold amount of $2010 when Medicare denies payment for failure to use the -KX modifier to indicate that the services are medically necessary as justified by documentation in the medical record. In order for the therapy provider to transfer liability to the beneficiary he/she must issue a valid ABN Form CMS-R-131.
In answering the question “How does a therapist or therapy provider handle services that Medicare would never cover? CMS responds by indicating that “An ABN is not needed for services that Medicare would never cover. If desired, a voluntary ABN can be issued to the patient.” The example provided is that of a beneficiary who had received PT for low back pain, and was discharged from the PT episode of care when she reached her goals. At this point she opted to pay out-of-pocket for Tai Chi classes offered as part of the PT Wellness Programs open to other community members.
The CMS updated FAQ document for the Therapy ABN also provides information on the $2010 and $3000 thresholds, as well as the use of modifiers. Of note, a provider cannot use the -KX modifier to indicate that therapy over the threshold is medically necessary, at the same time issuing an ABN to a beneficiary with the -GA modifier. The -GA modifier indicates that therapy is not medically necessary, and if properly completed and coded to the claim transfers financial liability to the beneficiary.
Does your practice have the most current ABN form? Do you know how to complete the ABN with all the required elements? Do you know when an ABN is voluntary?