Advance Beneficiary Notice of Noncoverage Frequently Asked Questions Document Now Available
On May 1, CMS released a new Frequently Asked Questions (FAQ) document on Advance Beneficiary Notice of Noncoverage. Please view the new FAQ document, or find it in the Downloads section below.
Jimmo v. Sebelius Settlement Agreement (Fact Sheet)
On January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius. For additional information, please see the Jimmo v. Sebelius Settlement Agreement Fact Sheet.
Extension of the Therapy Caps Exceptions Process
On February 22, 2012, President Obama signed into law the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA), which extends the exceptions process for outpatient therapy caps for the remainder of calendar year (CY) 2012. Outpatient therapy service providers may continue to submit claims with the KX modifier, when an exception is appropriate, for services furnished through December 31, 2012. Follow manual policies that apply when exceptions are in effect.
Because the therapy caps are determined on a calendar year basis, all patients began a new cap year on January 1, 2012. For physical therapy and speech-language pathology services combined, the limit on incurred expenses is $1,880 in 2012. For occupational therapy services, the limit is $1,880 in 2012. Deductible and coinsurance amounts applied to therapy services count toward the amount accrued before a cap is reached.
Section 3005 of the MCTRJCA also made several other changes affecting outpatient therapy services. The provisions that are effective on October 1, 2012, include: applying the therapy caps to outpatient hospitals, creating two new threshold amounts of $3,700 (one for each therapy cap amount), and requiring a manual medical review process of claims over these new thresholds. All of the above, with the exception of the manual medical review requirement, were addressed through CR 7785. Please see the drop down on this webpage entitled Therapy Services Transmittals to view CR7785 and corresponding manual changes.
For information about the MCTRJCA-required manual medical review process, please visit the Medical Review Website.
For information about 2012 Medicare Limits on Therapy Services, please view the:
Other Therapy Changes
The MCTRJCA requires the National Provider Identifier (NPI) of the physician or nonphysician practitioner (NPP), as applicable, certifying the therapy plan of care (POC) to be reported on all claims for therapy services. This permanent provision of the law becomes effective for claims with dates of services on and after October 1, 2012. The NPI-related instructions are found in CR 7785.
In addition, the MCTRJCA requires CMS to implement, by January 1, 2013, a claims-based data collection strategy related to patient function. This requirement is being addressed through the rulemaking process; and, will be included in the CY 2013 proposed rule for Medicare policies under the physician fee schedule expected to be release in early July. It will be available on the Physician Fee Schedule Federal Regulation Notices webpage.
Medicare Part B provides coverage and payment for outpatient therapy services, including, physical therapy (PT), occupational therapy (OT), and speech-language pathology services (SLP); and, for PT, OT, and SLP services provided under the comprehensive outpatient rehabilitation facility (CORF) benefit. This document serves as a guide to direct professionals to additional resources regarding rehabilitation therapy services, coverage requirements, payment systems, and points of contact for further information.
The Medicare contractor who pays your claims is the best source of answers to specific Medicare questions. Medicare Contractors (Carriers/ Intermediaries/ A/B Medicare Administrative Contractors) interpret Medicare laws, develop local policies, and educate providers. To find local coverage policy and other general instructions, contact your Medicare Contractor using the Provider Call Center Toll-free Numbers Directory which includes phone numbers and website addresses (see “Downloads” section below).
If you are have difficulty communicating with your contractor, use the CMS Regional Offices' web page (see “Related Links Inside CMS” section below) to identify the CMS Regional Office servicing your area of operations and utilize either the toll-free number or mailing address for assistance.
- Advanced Beneficiary Notice of Noncoverage Frequently Asked Questions [PDF, 46KB]
- MPPR Rate File 2013 [ZIP, 925KB]
- Medicare Claims Processing Manual, Chapter 5, Sections 10, 20, 30, 40, 100 [PDF, 292KB]
- Medicare Benefit Policy Manual, Chapter 15, Sections 220 and 230 [PDF, 1MB]
- Chapter 12 - Comprehensive Outpatient Rehabilitation Facility (CORF) Coverage [PDF, 103KB]
- 2009 Annual Update to the Therapy Code List
- CMS Regional Offices
- National Correct Coding Initiative Edits
- American Physical Therapy Association (APTA) - Opens in a new window
- American Occupational Therapy Association (AOTA) - Opens in a new window
- American Speech-Language-Hearing Association (ASHA) - Opens in a new window
- Page last Modified: 05/01/2013 5:01 PM
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