OT benefits once plateaued?

[ncsorice]

Hi,

I am a new Office Manager to OT practice. The Therapists here do not want to bill Medicare if the patient has plateaued or they just come here for Maintenance (only once a week). Their stance is, it is not medically necessary and billing to Medicare would be fraudulent.

We have two patients who want us to bill Medicare as they have the OT benefits.

I see both sides of the story. Does anyone have any input and know what is Correct?

I appreciate the help.

Thank you.
Coleen Sorice

[tdml97@yahoo.com]

I bill for PT/OT to Medicare - once their benefits "max out" you bill the charges with a modifer KX & claims are paid.

Does this help?

[dclark7]

Once a pateint has plateaued they hopefully have done a revised treatment plan. At that point it treatment is no longer medically necessary according to Medicare guidelines the patient should sign an ABN. Once the ABN is signed you can submit to Medicare with the GA modifier. The patient has the right to request that claims be submitted to Medicare. However, if the treatment isno longer medically necessary and you do not obtain an ABN, conitnue to tret the patint and submit the claims to Medicare they will be denied with NO patient responsibility. So in effect without the ABN and GA modifier you will be providing free treatment.

If you go to the CMS website you can find info on the ABN and when to use it https://www.cms.gov/Outreach-and-Edu..._ICN006266.pdf

[Cyndi113]

You can tell the patients that unless they are making measurable and functional progress, their therapy is considered not medical necessary. If they have plateaued, then no billing to Medicare is possible. I agree with the above about the ABN and modifiers.

I so remember those days and having to approach patients with this news. Enjoyed the patients and our interactions but so did not like giving them the "bad" news.