Advance Beneficiary Notice Archives | WebPT


The Ins and Outs of ABNs

If the rules of Advance Beneficiary Notices of Noncoverage (ABNs) make you a bit confused, you’re definitely not alone. In an effort to shed some light on the ins and outs of ABNs and to highlight some recent changes to ABN requirements, Medicare created this set of FAQs clarifying their use. Here’s some info to help bring you up to speed:

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The Complete PT Billing FAQ

Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.)

Questions related to:

• WebPT
• Modifier 59
• Other Modifiers
• Coding
• ICD-10
• Advance Beneficiary Notice (ABN) of Noncoverage
• Claims
• Contracts and Fee Schedules
• 8-Minute Rule
• Functional Limitation Reporting
• Cash-Pay Patients


How does WebPT help me bill better?

WebPT prompts users to apply modifier 59.

When WebPT detects that you have billed two codes that form a CCI edit pair, the system will alert you and ask whether you performed these services separately and distinctly of one another—and, therefore, should receive payment for both. If you attest that this is the case, WebPT will automatically apply modifier 59 to the appropriate code.

For WebPT Members

To activate this feature, please follow the steps below. Note that you’ll need to complete these steps for each insurance plan. We recommend applying this to commercial and government plans only (i.e. no workman’s compensation, legal/lien, and auto liability policies).

  1. Select “Display Insurance,” located on the left side of the WebPT Dashboard.
  2. Click “Edit” on the individual insurance for which you want to activate the feature.
  3. Once the insurance editing screen opens, check “Apply CCI edits”; then, select “Save.”
For Non-WebPT Members

If you’re not yet a WebPT Member, you can see this functionality and an array of other awesome features in a free, live online demonstration. Request one here.

WebPT tracks the therapy cap.

WebPT offers the Medicare Cap Report, which enables you to view Medicare beneficiaries’ progress toward the therapy cap and see whether therapists have affixed the KX modifier for those patients who have, in fact, exceeded the cap. In addition to tracking the therapy cap, WebPT alerts providers when a patient is:

  • approaching the cap
  • exceeding the cap (time to attach the KX modifier!)
  • approaching the manual medical review threshold ($3,700)
  • exceeding the manual medical review threshold

To learn more about the Medicare Cap Report and WebPT’s other compliance reporting and tracking capabilities, check out this blog post.

WebPT calculates the 8-minute rule.

As this blog post explains, “WebPT automatically double-checks your work for you and alerts you if something doesn’t add up correctly. All you have to do is record the time you spend on each modality as you go through your normal documentation process, along with the number of units you wish to bill. If those two totals don’t jibe, WebPT will not only let you know something’s off, but we’ll also tell you whether you overbilled or underbilled. That way, you can quickly identify and fix the problem—and thus, ensure accurate payment. Plus, you’ll have a detailed record of the services you provided on each date of service—something many local MAC auditors request to substantiate billing claims and processes.”

WebPT handles PQRS reporting.

WebPT is a certified PQRS registry. This means we collect PQRS claims data and submit it to Medicare on your behalf. We also have all the PQRS reporting requirements in our system, so depending on the Medicare beneficiary and visit, we’ll prompt you to complete the appropriate measure. Learn more about PQRS with WebPT.

What diagnosis code flows over from WebPT into my billing?

When you use WebPT, your treatment diagnosis is the one that is billed—not the medical diagnosis.

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Senate Repeals SGR in Landslide Vote

Well, folks, the fix is in—the fix for the sustainable growth rate (SGR), that is. In a 92 to 8 vote, the Senate approved the SGR repeal bill, called HR2. In addition to an SGR repeal, the bill also officially extends the therapy cap exceptions process until December 31, 2017. This result is better than no therapy cap exceptions process at all; however, it’s disappointing to know that we came so close to achieving a full repeal of the therapy cap.

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Senate Recesses with No Decision on SGR Bill

On Wednesday, April 1, 2015, SGR will go into effect, cutting reimbursements by roughly 20% and eliminating the therapy cap exceptions process—which means therapists will face hard caps at $1,940 for OT and $1,940 for PT and SLP combined.

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Common Questions from our Modifier Open Forum

No, by having your patient sign an ABN, you are acknowledging that you do not believe that the services you are providing are either medically necessary or covered by Medicare. If you have an ABN on file, you should include a modifier GA or GX modifier on your claim so Medicare knows to deny the claim and assign financial responsibility to the patient.

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The Great Medically Necessary Discussion and How to Use ABNs

For many physical therapists, the phrase “medically necessary” sounds worse than nails on a chalkboard. On the one hand, it’s vague, subjective, and open to infinite interpretation. And on the other, it’s often the determining factor in whether payers—perhaps most notably, Medicare—will provide reimbursement for rehab therapy services.

A Bit of History

The history of the “medically necessary” reimbursement requirement stretches all the way back to the 1960s. As E. Haavi Morreim explains in this article, it was around that time that soaring healthcare costs prompted insurers to create some kind of standard for payment. Up until that point, claim approval was based almost entirely on “physicians’ judgments about what care a patient needed.” When insurers realized they needed to define limits for coverage in order to control costs, they introduced the term “medically necessary” to combat the reimbursement of services that were “excessive, experimental, or merely convenient.”

While early guidelines as to what, exactly, made a service “medically necessary” were based on the collective clinical judgment of medical providers, the tables have since turned so that the health plans “tell physicians, rather than ask them, what is necessary and what is not,” Morreim writes. The pickle therapists run into is that the core meaning of the word “necessary”—whose synonyms include “essential” and “indispensable”—implicates a life-or-death situation in which the absence of care could directly result in loss of life. Of course, that’s not the standard most insurers adhere to when deciding whether to deny a claim; otherwise, the vast majority of medical care—including rehab therapy—would not warrant coverage.

The Necessity Umbrella

Without a clear definition as to what falls under the umbrella of “medical necessity,” payers have resorted to creating their own definitions based on their own cost-benefit analyses. Essentially, they ask:

  1. whether the cost of treatment justifies the chances that the patient will reach a desired level of relief or functional improvement.
  2. whether the treatment will mitigate the patient’s risk of suffering an even worse outcome if the current condition is left untreated.

The problem, Morreim writes, is that “a huge array of treatments fits that description: more or less worthwhile, but the patient will not die without it and other alternatives (that might have some drawbacks) exist.” Furthermore, definitions of medical necessity can vary from one health plan to the next, though most share a decidedly vague set of conditions. This is particularly frustrating for rehab therapy professionals because, as Morreim points out, “the vague concept of ‘necessary’ does not fit quality of life-oriented interventions very well,” which makes it “easy for health plans to dub those interventions discretionary and unnecessary.”

Defining Necessity for Physical Therapy

To help both physical therapists and payers better understand and apply the concept of medical necessity as it relates to therapy services, the APTA adopted the Defining Medically Necessary Physical Therapy Services position in 2011. According to this statement, “physical therapy is considered medically necessary as determined by the licensed physical therapist based on the results of a physical therapy evaluation and when provided for the purpose of preventing, minimizing, or eliminating impairments, activity limitations, or participation restrictions.” Furthermore, therapy treatment is considered medically necessary “if the type, amount, and duration of services outlined in the plan of care increase the likelihood of meeting one or more of these stated goals: to improve function, minimize loss of function, or decrease risk of injury and disease.”

This description might not fall in line with every single “medically necessary” definition out there, but it does provide a better level of therapy-specific detail than most. It also seems to be on par with Medicare’s reimbursement requirements, especially considering the recent court decision that definitively eliminated patient improvement as a condition of payment.

The Therapy Cap and ABNs

Speaking of Medicare, as you’re probably well aware, Medicare caps the total amount of reimbursement it will provide annually for each patient’s rehabilitation services. For 2014, that amount is $1,920 for occupational therapy and $1,920 for physical therapy and speech-language pathology combined. Therapists can treat above the cap—at least, they can until March 31, 2014. However, Medicare’s reimbursement above the cap hinges on the medical necessity of continued therapy treatment. Per the APTA, “an automatic exception to the therapy cap may be made when the patient’s condition is justified by documentation indicating that the beneficiary requires continued skilled therapy, i.e., therapy beyond the amount payable under the therapy cap, to achieve their prior functional status or maximum expected functional status within a reasonable amount of time.” (For an in-depth discussion of the therapy cap, check out this blog post.)

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Wellness and Cash-Based Services for Medicare

Today’s blog post comes from Ann Wendel, PT. Ann is the owner of PranaPT, a member of WebPT, and an active social media participant (@PranaPT). Thanks, Ann! Due to all of the recent changes in Medicare documentation and billing requirements, I have had an increase in the number of questions from other physical therapists regarding cash-based services for Medicare patients.

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