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Outpatient Occupational and Physical Therapy Services Billing Guide
- Introduction to Outpatient OT and PT Services
- Outpatient Occupational and Physical Therapy Coverage
- Caregiver Training Services
- KX Modifier Threshold
- 2024 Annual Update to the Therapy Code List: Remote Therapeutic Monitoring
- Annual Update to the Therapy Code List
- Targeted Medical Review
- Functional Reporting - Using the G Codes
- What is the Advance Beneficiary Notice of Noncoverage and When to Use It in Outpatient Therapy
- Maintenance Programs
- Multiple Procedure Payment Reduction
- The National Correct Coding Initiative
- Comprehensive Error Rate Testing Program
- Recovery Auditor
- Common Billing Errors and Remittance Message
- Medical Review Therapy Documentation Checklist for Additional Development Request Letters
- Common Questions and Answers
- Related Content
- Related Articles
What is the Advance Beneficiary Notice of Noncoverage and When to Use It in Outpatient Therapy
The ABN is a notice given to the Medicare patient before services are rendered when you believe Medicare may deny services. These may be for medical necessity purposes, when services are no longer medically necessary, whereas they once were covered.
Therapy Threshold and ABN Use
| Therapy Threshold | ABN |
|---|---|
| Not Met | A patient wants to continue therapy services, but you feel they have improved to the maximum potential.
|
| Not Met | The ABN can be used as a courtesy to notify patients when Medicare may never cover services.
|
| Met | If a patient exceeds the established KX modifier threshold amount and you feel services are no longer medically necessary, do not utilize the exception process by affixing a KX modifier to your coding.
|
KX and GA Modifiers
If the services beyond the cap are medically necessary, affix the KX modifier. The KX modifier indicates that the services are medically necessary. Therefore, it would be inappropriate to present an ABN.
- Medicare covers therapy services above the KX modifier threshold that are reasonable and necessary, and supported by appropriate documentation.
- Providers cannot transfer liability to a beneficiary when using the KX modifier.
- The beneficiary is liable only for applicable co-pays and deductibles for covered therapy services.
Never use KX and GA modifiers together; these are opposing modifiers.
- If you feel services are not medically necessary and have started using the KX modifier, you must stop using the KX modifier and begin using the GA modifier.
The ABN must follow specific regulations for completion and be given to the patient before the services are rendered so they can choose whether or not they would like the service and pay out of pocket for it.
- When filling out the ABN, ensure all options are presented to the patient.
- The patient must be able to make an informed decision; if unable, a caretaker/power of attorney can decide for them.
- Ensure the ABN is filled out completely; leaving a section blank will disqualify the use of the ABN.
- Retain a copy of the ABN for your records.
- Follow all guidelines for using an ABN when the therapy threshold has been met.
Related Content
- CMS MLN® Booklet: Medicare Advance Written Notices of Non-coverage
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 30
- Beneficiary Notices Initiative (BNI)
- Outpatient Therapy Services and ABN, Form CMS-R-131, August 2018
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 5
Reviewed 10/07/2024