Medicare Compliance & Reimbursement

They can't reach for HHABNs either.

Home health providers can avoid unnecessary extra work if they furnish outpatient therapy to patients in the home--but they must heed new guidance from the feds.

Patients who exceed the new $1,740 annual cap for either occupational therapy or physical therapy and speech therapy combined aren't eligible for the expedited determination process, the Centers for Medicare & Medicaid Services explains in new questions-and-answer postings. The cap applies only to Part B therapy, not therapy under the home health benefit.

"Exceeding the therapy cap does not trigger the expedited right," CMS explains in the Q&A. "The cap is set in law and once it is exceeded, [Quality Improvement Organizations] cannot contradict or reinterpret the law."

CMS compares exceeding the outpatient therapy cap to exceeding the 100-day coverage limit in a skilled nursing facility Part A stay. "Providers never issue generic notices based solely because benefits exhaust," the agency instructs.

This answer makes sense, because "what's left to appeal?" asks Casey Blumenthal with MHA...An Association of Montana Health Care Providers. "If there is no more benefit, there is no more benefit."

Exceeding the therapy cap "is actually more definitive than in regular home health visits, because sometimes the 'skilled' status is less black and white" than the cap numbers, Blumenthal says. "One can argue the former, but not the latter."

Home care providers that want to continue furnishing Part B therapy to patients who have exceeded the cap may want to issue an advance beneficiary notice to make the patients' financial liability for the services clear, legal experts note.

But providers shouldn't use the home health-specific ABN. "The new instructions regarding the HHABN wouldn't seem to apply" to Part B therapy, observes attorney Robert Markette Jr. with Gilliland Markette & Milligan in Indianapolis. Instead, "the old rules on the general ABN would apply."

The HHABN is specifically for home health services, agrees consultant Judy Adams with LarsonAllen Health Care Group, based in Charlotte, NC. That's in contrast to the expedited determination notices, which many types of providers require.

Note: The general ABN is available at www.cms.hhs.gov/BNI/02_ABNGABNL.asp.