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However, despite a longstanding push to repeal the cap, Congress has continued to renew it each year since it was first established. Still, to ensure the cap does not prevent Medicare patients from obtaining medically necessary care, Congress also has passed legislation every year that allows exceptions for exceeding the cap.
Inthere is a two-tiered exceptions process. What is Included in the Therapy Cap? Beginning inthe therapy cap—along with the rules governing the therapy cap exceptions and manual medical review processes—applies to critical access hospitals in the same manner as all other settings.
Each time a new Medicare patient comes to you for treatment, it is crucial that you determine whether the patient has received any other therapy services during the current benefit period, as those services would apply to the cap.
To calculate the patient's "running total" toward the therapy cap, you can reference the allowable fee schedule.
In the event that the patient can't provide you with a history of the therapy services he or she has received, you can request this information from CMS by contacting your Medicare contractor.
Keep in mind that the amount that goes toward the limit reflects the date of claim receipt, not the date of service. What is the Therapy Cap Exceptions Process? Automatic Exceptions The therapy cap isn't necessarily the end-all, be-all of reimbursement for a particular patient.
If you believe that continuing therapy with a patient is medically necessary—thus qualifying the patient for an exception to the cap—all you have to do is attach the KX modifier and clearly document your reasons for continuing treatment. This is known as the automatic exceptions process.
With this change, MACRA now prohibits the use of recovery auditors to conduct these reviews; instead, CMS has selected Strategic Health Solutions as the supplemental medical review contractor SMRC and tasked it with performing the reviews for all payers on a post-payment basis. The SMRC will select claims for review when: Providers with a high percentage of patients receive therapy beyond the thresholds as compared to other industry professionals during the first year MACRA is in effect; and Therapy is provided in skilled nursing facilities SNFsprivate practices, or outpatient physical therapy, speech-language pathology, or occupational therapy clinics.
Losing your mind over modifiers? Watch our Modifier Open Forum webinar to learn how and when to use them. If you would like to continue therapy for a patient who has exceeded the cap but does not qualify for an exception, you can do so through the use of an Advance Beneficiary Notice ABN of Noncoverage.
This allows a patient to keep receiving therapy that is no longer medically necessary. Essentially, an ABN notifies a Medicare patient that Medicare might not cover the therapy services he or she is about to receive and serves as proof that the patient understands his or her financial obligation.
By signing an ABN, the patient agrees to pay for treatment out-of-pocket or through a secondary insurance. You must issue an ABN: Before providing items or services that you believe or know Medicare may not cover.
Before providing items or services that Medicare usually covers but may not consider medically reasonable and necessary for a specific patient in a specific case. In neither case can you issue an ABN after Medicare has already denied a claim. You must always have patients sign the form before you provide the services in question.
In general, though, the medical necessity of services is determined based on: To shed light on the meaning of medical necessity and how it applies to physical therapists, the APTA released the Defining Medically Necessary Physical Therapy Services position in If you conclude that certain services are not medically reasonable and medically necessary based on the definition that applies to you—and thus, you issue an ABN—then you should add the GA modifier to the claim to signify that you have an ABN on file.
Please note that if you are using the GA modifier, you should not use the KX modifier. You will still continue to submit claims to Medicare, but the GA modifier will prompt Medicare to reject them. Then, once you receive Medicare's denial, you can go ahead and collect out-of-pocket payment.
Remember, you should not issue an ABN for every beneficiary who exceeds the therapy cap—only ones for whom the services in question do not fall under Medicare's definition of "reasonable or necessary.Programs and services that support the employees and stakeholders in state government enterprise.
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One cap is for PT and SLP services combined and another cap is for OT services. In order to accrue incurred expenses to the correct therapy cap, one of the three therapy modifiers − GN, GO. Compare prices with cheap auto insurance to find the best deals. This site makes it easy to start saving money right away with your next policy.
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