Getting paid: Don’t charge patient when therapy charges exceed annual cap without ABN

Why This Topic Matters

The policy affects whether a provider or patient is financially responsible for denied therapy charges and whether prior beneficiary notice is required before billing. Understanding the update helps practices avoid improper patient billing, identify remittance advice issues, and respond appropriately to retroactive payment liability changes.

Article Sections

1. Medicare therapy cap payment liability update

   Overview of the policy change affecting therapy claims that exceed the annual cap and the resulting billing implications for practices and beneficiaries.

2. Remittance advice and contractor reporting issues

   Discussion of how denial information is being reported and why the remittance advice data may not yet reflect the updated liability assignment.

3. Effective date and retroactive application

   Summary of the timing of the change, including the stated implementation period and its retroactive effect on earlier claims.

4. ABN and modifier guidance for therapy claims

   General guidance on the documentation and claim-processing elements tied to therapy services that exceed the cap and the related Medicare contractor instructions.

5. Official resource

   Reference to the cited Medicare transmittal and source document.