Practice Management Alert

Question: Since the Senate and House overruled the veto of Congressional bill H.R. 6331, does that mean we can bill patients for services over the therapy cap if they signed a NEMB?

Oklahoma Subscriber

Answer: The new legislation reinstated the therapy cap exceptions process, effective retroactive to July 1. "Claims submitted with the therapy cap exception modifier [modifier KX] will be processed as soon as the payment rates have been activated," a July 16 CMS memo stated. "Claims submitted without the modifier, and rejected or denied, can be resubmitted with the modifier for reimbursement."

You will not use a notice of exclusions from Medicare benefits (NEMB) for therapy services, however. CMS discontinued the NEMB earlier this year and wrapped it into the new advance beneficiary notice (ABN). The new ABN covers non-covered services as well as non-medically necessary services all in one form.

Old way: In case you weren't familiar with exactly when you were supposed to use the ABN rather than the NEMB, keep in mind that in the past, ABNs were only for procedures that Medicare might not cover because Medicare deemed them not medically necessary. The ABN didn't apply to procedures that were statutorily excluded from Medicare benefits. That was where the NEMB came in -- you were able to use it for services such as therapy services beyond the therapy caps (that didn't fall under an exception) because Medicare never covered them.

Now CMS will accept the new ABN form for either purpose, noting in its ABN instructions that "the revised version of the ABN may also be used to provide voluntary notification of financial liability."

More information: You can find the new ABN form at http://www.cms.hhs.gov/BNI/02_ABNGABNL.asp.