MLN Matters Number: MM6321 Revised
Related Change Request (CR) #: 6321
Related CR Release Date: February 13, 2008
Effective Date: January 1, 2009
Related CR Transmittal #: R1678CP
Implementation Date: April 6, 2009
Note: This article was revised on March 10, 2009, to clarify the Advance Beneficiary Notice (ABN) language. All other information remains the same.
Provider Types Affected
Physicians, providers, and suppliers submitting claims to Palmetto GBA for therapy services provided to Medicare beneficiaries.
Provider Action Needed
This article is based on Change Request (CR) 6321, which describes the Centers for Medicare & Medicaid Services (CMS) policy for outpatient therapy cap exceptions for 2009 and updates the dollar amount of the therapy caps for 2009. Be sure billing staff is aware of the updates.
Background
The Balanced Budget Act of 1997 established limits on outpatient therapy services. These limits change annually. The Deficit Reduction Act of 2005 allowed CMS to establish an exceptions process, which began January 1, 2006, and was extended by later legislation. The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) extended the exceptions process for therapy caps through December 31, 2009. CR 6321 makes no change to the exceptions process.
CR 6321 revises the Medicare Claims Processing Manual Chapter 5, Section 10.2 (The Financial Limitation) to include the outpatient therapy cap exceptions for 2009. The revised manual chapter is included as attachment to CR 6321 and the following is extracted from that attachment:
Financial limitations on outpatient therapy services, as described in the Medicare Claims Processing Manual (Chapter 5, Section 10.2 (The Financial Limitation)) were $1740 in 2006, $1780 in 2007 and $1810 for 2008.
For 2009:
- The annual limit on the allowed amount for outpatient physical therapy and speech-language pathology combined is $1840
- The separate limit for occupational therapy is $1840
The Advance Beneficiary Notice (ABN) must be used to inform a beneficiary whenever the treating clinician determines that the services being provided are no longer expected to be covered because they do not satisfy Medicare's medical necessity requirements before the cap is reached. The ABN informs the beneficiary of their potential financial obligation to the provider and provides guidance regarding appeal rights. Since therapy that exceeds the cap is statutorily excluded from Medicare coverage, the ABN is not required. However, the ABN may be used on a voluntary basis to inform the beneficiary of potential liability for therapy that exceeds the cap.
Note: The ABN-G was no longer effective March 1, 2009. After that date providers must use the revised ABN (CMS-R-131), which is available for download at www.cms.hhs.gov/BNI/Downloads/ABNFormInstructions.zip. (This link provides the instruction and ABN form in both English and Spanish.)
Additional Information
The official instruction, CR 6321, issued to Palmetto GBA regarding this change may be viewed at www.cms.hhs.gov/Transmittals/downloads/R1678CP.pdf (PDF, 729 KB).
If you have any questions, please contact our Provider Contact Center at our toll-free number, (866) 332-7025 (Ohio and West Virginia) or (888) 828-2092 (South Carolina Part B).
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.