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The Centers for Medicare and Medicaid Services (CMS) have published implementation instructions for the Medicare therapy caps on outpatient services, which are scheduled to return July 1—though ASHA continues to advocate for their permanent repeal. The full implementation instructions (AB-03-018) can be found on the CMS Web site at http://www.cms.hhs.gov/Transmittals/Downloads/ab03018.pdf.
Unless Congress repeals them before this summer, the caps will be applied per beneficiary, with tracking of the beneficiary expenses, beginning July 1. To appropriately track the financial limitations, CMS will require speech-language pathologists to use a GN modifier when billing for their outpatient Medicare services. By law, the cap must be updated yearly to reflect the Medicare Economic Index. This year, the capped amount for Medicare physical therapy and speech-language pathology services will be $1,590. This amount includes appropriate deductibles and coinsurance.
CMS states that it is the provider’s responsibility to inform patients of the implications of the cap. SLPs should begin notifying their patients of the upcoming implementation of the cap. Beneficiaries must be advised that any claims for services that exceed the $1,590 limit will be the patient’s responsibility, unless the beneficiary chooses to receive additional necessary care from a hospital outpatient facility. CMS is advising all providers to use a Notice of Exclusion From Medicare Benefits (NEMB) form to advise beneficiaries of the therapy caps during the first encounter with the patient. The NEMB form can be found at www.cms.hhs.gov/ medlearn/refABN.asp .
When using the NEMB form, SLPs should check Box #1 and indicate in the space provided that Medicare will not pay for physical therapy and speech-language pathology services over $1,590 for dates of service between July 1 and Dec. 31, 2003.
ASHA is preparing a mailing to all SLPs practicing in health care settings that will provide additional information on the therapy caps, as well as a request for grassroots advocacy urging Congress to repeal the caps and to permit Medicare beneficiaries access to outpatient services from SLPs in private practice. For additional information on the implementation of the therapy caps, contact Ingrida Lusis by e-mail at ilusis@asha.org or through the Action Center at 800-498-2071, ext. 4482.
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