Page 187 - Medicare Benefit Policy Manual

that services were not furnished under proper supervision, it shall deny the
claim and bring this matter to the attention of the Division of Survey and
Certification of the Regional Office.

• While a beneficiary’s particular medical condition is a valid factor in deciding
if skilled therapy services are needed, a beneficiary’s diagnosis or prognosis
cannot be the sole factor in deciding that a service is or is not skilled. The key
issue is whether the skills of a therapist are needed to treat the illness or
injury, or whether the services can be carried out by nonskilled personnel. See
items C and D for descriptions of covered skilled services; and

• The amount, frequency, and duration of the services must be reasonable under
accepted standards of practice. The contractor shall consult local
professionals or the state or national therapy associations in the development
of any utilization guidelines.

NOTE: Claims for therapy services denied because they are not considered reasonable
and necessary under §1862(a)(1)(A) of the Act and, for services furnished on or after
January 1, 2013, those denied as a result of application of the therapy caps under
§1833(g)(1) or (g)(3) are subject to consideration under the waiver of liability provision
in §1879 of the Act. Although Section 50202 of the Bipartisan Budget Act (BBA) of
2018 repealed the therapy caps and its exceptions process effective January 1, 2018, it did
not change provider liability procedures which first became effective January 1, 2013.
Section 1833(g)(8) of the Social Security Act (as redesignated by the BBA of 2018)
continues to provide limitation of liability (LOL) protections to beneficiaries receiving
outpatient therapy services on or after January 1, 2013, when services are denied for
certain reasons, including failure to include a necessary −KX modifier. (Section 1879
provides LOL protections for reasonable and necessary denials more generally.) Under
section §1833(g)(8), the therapist or therapy provider is financially liable for the cost of
therapy services provided to a beneficiary above the threshold amount when Medicare
denies payment for failure to use the −KX modifier to indicate that the services are
medically necessary as justified by documentation in the medical record. In order for the
therapist or therapy provider to transfer liability to the beneficiary, s/he must issue a valid
ABN, Form CMS-R-131. For more information, see the Therapy Services webpage at:
https://www.cms.gov/Medicare/Billing/TherapyServices/index.html for the Advance
Beneficiary Notice of Noncoverage (ABN) Frequently Asked Questions (FAQ)
document that was posted to reflect the changes of the Bipartisan Budget Act of 2018.
Please find the document titled: “August 2018 ABN FAQs” in the Downloads section on
this webpage.

C. Rehabilitative Therapy

Rehabilitative therapy includes services designed to address recovery or improvement in
function and, when possible, restoration to a previous level of health and well-being.
Therefore, evaluation, re-evaluation and assessment documented in the Progress Report
should describe objective measurements which, when compared, show improvements in