Medicare Compliance & Reimbursement

Confusion reigns when it come to ABNs.

If the ABN and its cousin the NEMB are throwing you for a loop, you're not alone. Here's a guide to finding the right form when therapy caps are involved.

Scenario: A resident exceeds or is about to exceed the therapy cap(s) and does not qualify for any exceptions.

You may use the Notice of Exclusions from Medicare Benefits form, though the Centers for Medicare and Medicaid Services does not require its use.

In this case, the Advance Beneficiary Notice does not apply because "therapy over the cap is not considered a benefit under the law and therefore is a benefit category denial," said a CMS official at the recent Skilled Nursing Facility/Long-Term Care Open Door Forum.
The NEMB is applicable, however. It is designed to inform beneficiaries when Medicare doesn't cover a service.

In this case, you should use the NEMB to explain to your beneficiaries that your services above the $1,740 cap are not a Medicare-covered benefit.

Within the NEMB you should check "box #1 and give the following reason for denial: 'Medicare will not pay for physical therapy and speech-language pathology services over $1,740 in 2006,'" says CMS on its Q&A Web site.

Good idea: While the NEMB does not include a patient signature block, CMS advises you and your therapists to add this to the form or have a signed document in the patient's records indicating that she has received the NEMB or a similar notification.

Remember: The ABN is for services that Medicare will "probably not pay for," usually due to medical necessity stipulations. The ABN also requires the patient to choose between refusing the services or receiving them and paying out-of-pocket.

Get the Advance Beneficiary Notice at www.cms.hhs.gov/BNI/Downloads/CMSR131G.pdf and the Notice of Exclusions from Medicare Benefits at www.cms.hhs.gov/BNI/Downloads/CMS20014.pdf.