ABN (Advance Beneficiary Notice) and 2008 Therapy Cap Limitations

Effective January 1, 2008 the Financial Limits on Outpatient Therapy Services as mandated per CMS CR5871 are as follows:

Physical Therapy and Speech Language Pathology (Combined) - $1810
Occupational Therapy - $1810

The Balanced Budget Act of 1997 enacted financial limitations on therapy services.  In recent years, Congress has legislated allowable exceptions to the annual Financial Limitation for Therapy Services (known as therapy caps).  This legislation currently allows providers to submit claims for medically necessary therapy services in excess of the therapy caps through June 30, 2008.

As July 1, 2008 approaches, providers should be aware of those patients who are nearing the therapy cap limitations.  Those patients who still require therapy must be advised of their rights to continue services through the ABN or NEMB process and offered the opportunity to pay privately for these services.   Effective July 1, 2008, providers will not be paid for therapy services in excess of the therapy caps by the Medicare program.

The ABN is a notice given to beneficiaries in traditional Medicare to advise them that Medicare is not likely to provide coverage for specific services. The ABN must be verbally reviewed with the patient or his representative and it is the provider’s responsibility to ensure that all questions are resolved before it is signed.  As in the past the ABN must be delivered far enough in advance that the beneficiary or representative has time to consider and make an informed choice.  And remember, it is the provider’s responsibility to be able to prove receipt.

Providers must create the ABN on a single page.  They may place their logo at the top of the page by typing, hand-writing, using a label, or by other means. Providers must include at least the facility name, address and phone number to give the beneficiary contact information to be used for questions.  It is permissible for more than one item to be included on the ABN, however, the provider must be able to present this information in a manner that clearly matches the reason and cost information with each identified item of service.  The beneficiary or his/her representative must sign and date the ABN in the box marked “Signature” to acknowledge that they have received and understand the notice.

Instructions for completing the ABN are found in the Medicare Claims Processing Manual, Publication 100-04 Chapter 30.  OMB-approved ABN’s are placed on the CMS website at: http://www.cms.hhs.gov.BNI.  The form number for SNF ABN document is CMS-10055 (Rev. 10/01/03).