Reporting Unilateral or Bilateral CodesDecember 18th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Generally, Audiology tests are coded as if they were performed on both ears, if the testing was performed only on one ear, you are required to append a modifier to acknowledge there was a reduced service or a unilateral assessment, using modifier 52 - Reduced Services. (Be sure to read...Reciprocal Billing and Locum Tenens Arrangements ChangesNovember 26th, 2018 - Wyn Staheli, Director of Research
CMS has made changes to their payment policies for reciprocal billing arrangements and Fee-For-Time compensation arrangements (formerly referred to as locum tenens arrangements). Providers need to be aware of these changes and update their policies as appropriate.Muscle Testing and Range of Motion InformationNovember 8th, 2018 - Wyn Staheli, Director of Research
Be sure to understand the unique code requirements for Muscle and Range of Motion Testing.How to Use Modifier Indicators with NCCI Edits (2018-10-31)October 31st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
To verify if clinical circumstances might justify the use of a modifier when billing code pairs, look at the NCCI edits and the modifier indicator. Medicare may have restrictions on the use of a modifier used to bypass an edit. This important part of coding can alert a payer or ...Anesthesia and Pain ManagementOctober 31st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Anesthesia and Pain management is under close watch from the OIG according to a report from Anesthesia Business consultants, they stated, "The Health and Human Services Office of Inspector General (HHS OIG) reports in its most recent Semi-annual Report to Congress that in FY 2017 it brought criminal actions against 881 individuals or organizations ...Capped Rental ItemsOctober 26th, 2018 - Find-A-Code
CMS Gives guidance on Capped Rental Items:
Items in this category are paid on a monthly rental basis not to exceed a period of continuous use of 13 months.
Based on Supplier Standard 5, suppliers are required to advise beneficiaries of the rent/purchase option for capped rentals and inexpensive or routinely purchased items. ...Use My Code Set to Save Priced ProceduresOctober 2nd, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Use My Code Set to save priced procedures to refer to commonly used procedures. Once your CCI edits are done and you have your list of Codes, add notes to My Codes. Add all important information to the Code, for viewing again instead of re-working your most commonly used procedures....When to Use Modifier 25 and Modifier 57 on Physician ClaimsOctober 1st, 2018 - BC Advantage
The biggest thing modifiers 25 and 57 have in common is that they both assert that the E/M service should be payable based on documentation within the record showing the procedure should not be bundled into the E/M. After that, the similarities end, and it is important to know the...Using Modifiers 96 and 97August 16th, 2018 - Wyn Staheli, Director of Research
The Affordable Care Act (ACA) requires coverage of certain essential health benefits (EHBs), two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. ...Using ModifiersAugust 13th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Modifiers offer supplemental information and provide additional details without changing the procedure codes definition and are always two digits. Modifiers are required for proper billing and at times used with NCCI edits, however, two or more NCCI -associated modifiers on the same line will be denied. In addition, NCCI modifiers ...Home Oxygen Therapy -- CMN for OxygenJune 14th, 2018 - Raquel Shumway
The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.Preventive Medicine: Colorectal Cancer ScreeningMay 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page
Colorectal Cancer Screening
Procedure Codes G0104: Colorectal cancer screening; flexible sigmoidoscopy G0105: Colorectal cancer screening; colonoscopy on individual at high risk G0106: Colorectal cancer screening; screening sigmoidoscopy, barium enema G0121: Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G0122: Colorectal cancer screening; barium ...Preventive Medicine: Contraceptive MethodsMay 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page
Procedure Codes A4261: Cervical cap for contraceptive use A4266: Diaphragm for contraceptive use A4264: Permanent implantable contraceptive intratubal occlusion device(s) and delivery system J7300: Intrauterine copper contraceptive J7301: Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg J7303: Contraceptive supply, hormone containing vaginal ring, each J7304: ...Preventive Medicine: General ProceduresMay 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page
Procedure Codes 36415: Collection of venous blood by venipuncture 90471: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) 90472: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List ...Preventive Medicine: Human Papilomavirus (HPV) Vaccine and ScreeningMay 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page
Human Papilomavirus (HPV) Vaccine and Screening
Procedure Codes 87623: Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) 87624: Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, ...Preventive Medicine: Medical Nutrition Therapy and Cardiovascular Disease (CVD)/Obesity PreventionMay 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page
Medical Nutrition Therapy and Cardiovascular Disease (CVD)/Obesity Prevention
Procedure Codes G0270: Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, ...Preventive Medicine: Use of Modifier 33May 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page
The Use of Modifier 33
Modifier 33 is used to indicate Preventive Services to report quality metrics and is informational only, it has no impact on reimbursement. Modifier 33 should be reported only to private payers, Medicare and Medicaid do not recognize this modifier.
...Q/A: Modifiers for InjectionsApril 17th, 2018 - Nicole Olsen QCC
I'm currently receiving a rejection for my billing with BCBS. We've entered 20550 and 20600 as services for the visit....Billing Nutrition Counseling in a Chiropractic SettingApril 12th, 2018 - Wyn Staheli, Director of Research
Billing nutrition counseling services may not be as straight-forward as you might think. Some providers mistakenly choose Medical Nutrition Therapy (MNT) codes (97802-97804, G0270, G0271) because it states nutrition therapy in the title. However, according to CPT guidelines, when MNT assessment and/or intervention is performed by a physician or qualified healthcare professional ...Medicare Telemedicine Changes for 2018March 29th, 2018 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
Find-A-Code presented a webinar on “Coding and Auditing Telemedicine Services,” on March 29, 2018, which did not include the new and updated CMS information published in the MNL Matters Number: MM10393 on January 2, 2018. New and exciting changes were introduced in this article, which is addressed below.
Originating Site Fee
Each ...Q/A: Which Modifiers to Use When Billing 44005 and 36556 TogetherMarch 26th, 2018 - Chris Woolstenhulme QCC, CMCS, CPC, CMRS
I have a denial for 44005 and 36556 being billed together. I added modifiers 51, 59, and Q6 to 36556 but I am afraid it will deny again?Documentation for Surgical DressingsMarch 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for surgical dressings.Increased Therapy Denials Create Administrative BurdenMarch 5th, 2018 - Wyn Staheli, Director of Research
Recently, many healthcare providers have begun to experience a downpour of denials when billing therapy services. The states which seem to be experiencing the most difficulty are Illinois, Oklahoma and Texas, particularly for claims submitted to BCBS plans owned by Health Care Service Corporation (HCSC). Since HCSC also owns Blues ...New Bipartisian Budget Act of 2018 ProvisionsMarch 1st, 2018 - Wyn Staheli, Director of Research
On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. There were some changes which will affect Medicare payments. The following is a brief summary, for a more comprehensive summary see the References.
Therapy Caps: Some therapy caps (e.g., occupational, physical therapy, speech-language pathology) were discontinued. However, modifier KX will ...CPT Modifers 96 & 97 for Habilitative and Rehabilitative ServicesFebruary 27th, 2018 - Jared Staheli
Effective January 1, 2018, CPT modifiers 96 "habilitative services" and 97 "rehabilitative services" will be in effect. CMS has added modifiers 96 and 97 to their edits (see MLN Matters MM10385 here) and modifier SZ is deleted as of December 31, 2017. Private payers should simply adjust their policies to use ...OIG Issues Renewed Focus on Chiropractic ServicesFebruary 26th, 2018 - Wyn Staheli, Director of Research
The OIG recently released a "Portfolio" regarding chiropractic service which stated (emphasis added):
This portfolio presents an overview of program vulnerabilities identified in prior Office of Inspector General (OIG) audits, evaluations, investigations, and legal actions related to chiropractic services in the Medicare program. It consolidates the findings and issues identified in ...New Modifiers Released in 2018February 13th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
There were 13 new modifiers released in 2018, be sure you are using them if appropriate.
X-ray taken using computed radiography technology/cassette-based imaging
Drug or biological acquired with 340b drug pricing program discount
Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was ...Medicare Requiring Modifier GP on Physical Therapy ServicesFebruary 1st, 2018 - Wyn Staheli, Director of Research
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following (emphasis added):
Services furnished under the Outpatient ...Reporting Tooth Numbers and Oral Cavity AreasFebruary 1st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
When billing for dental procedures you need to identify the exact tooth and/or location in the oral cavity. Qualifiers are used to report the location and tooth number. When billing procedures on teeth and the oral cavity, the JP qualifier is used to identify the tooth number(s) and the JO ...Anesthesia Documentation Modifiers - Jurisdictions: J8A, J5A, J8B, J5BJanuary 29th, 2018 - Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
Documentation Modifiers direct prompt and correct payment of the anesthesia claims submitted. Documentation modifiers (AA, QK, AD, QY, QX and QZ) must be billed in the first modifier field.
If a QS modifier applies, it must be in the second modifier field. Processing delays and denials may occur for claims submitted ...Paravertebral Joint/Nerve Blocks - Diagnostic and TherapeuticJanuary 29th, 2018 - Find-A-Code
According to Medicare article A50443, a facet joint level refers to the zygapophyseal joint or the two medial branch nerves innervating that zygapophyseal joint. Use CPT codes 64491 and 64492 in conjunction with 64490. Do not report CPT code 64492 more than once per day. Use CPT codes 64494 and 64495 in conjunction with 64493. Do not report CPT code 64495 more than once per day. For injection of ...$4.6 million in Claims Paid Incorrectly by CMS when Using KX ModifierJanuary 16th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
$4.6 Million was paid by CMS for claims that did not comply with Medicare requirements. The claims were paid in 2017 and reported by the Office of Inspector General (OIG) stating, "A 2017 Office of the Inspector General (OIG) report noted that, in some cases, pharmacies incorrectly billed Medicare Part B ...Patient Relationship CodesJanuary 16th, 2018 - Wyn Staheli, Director of Research
Section 1848(r)(4) of MACRA requires that claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, include codes for the following:
care episode groups
patient condition groups
patient relationship categories
Previously, CMS decided to use procedure code modifiers to report patient relationship codes on Medicare ...Medicare Requiring Specific Modifiers on Therapy ServicesJanuary 15th, 2018 - Wyn Staheli, Director of Research
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following:
Services furnished under the Outpatient ...Billing with a GP ModifierJanuary 15th, 2018 - Wyn Staheli, Director of Research
Q: When patients have a true Medicare secondary insurance we've always billed other Medicare non-covered codes such as G0283 for electric stimulation with modifier GY because we are aware Medicare will not pay for that service but the secondary insurance does. We just were notified by our MAC that GY is not a valid modifier and I have to enter a GP or other therapy modifier. What is the new proper modifier to enter?Intensive Outpatient Treatment (IOP)January 11th, 2018 - Wyn Staheli, Director of Research
Intensive Outpatient Programs (IOPs) are considered to be an intermediate level of care which is commonly considered after the patient has been discharged from inpatient care. For some patients and/or conditions they can also provide an effective level of care when hospitalization is not clinically indicated or preferred. The following ...Advance Beneficiary Notice of Noncoverage (ABN) Modifier GuidelinesJanuary 11th, 2018 - Find-A-Code
The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, GX, GY, or GZ, as ...Diagnosis billing with J0888January 9th, 2018 - Find-A-Code
The following information is from LCD L36276.
The diagnosis codes listed below require the use of the EC modifier (ESA administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy) when submitting claims for J0888. In addition, these diagnosis codes are marked with an * indicating they require a dual diagnosis. The ...Outpatient Rehabilitation ModifiersJanuary 9th, 2018 - Jared Staheli
Modifiers are used for outpatient rehabilitation services to identify the type of service performed. This is necessary for payers to determine service coverage for beneficiaries.
For services delivered under an outpatient plan of care use modifier:
GN for speech-language pathology
GO for occupational therapy
GP for physical therapy
In addition to using the correct modifier, ...Preventive Medicine with a New PatientJanuary 9th, 2018 - Find-A-Code
When coding for preventive care, be sure to use the correct encounter code with the procedure as well as the appropriate modifier if required.
New Patient: A patient that has not received any professional services i.e., E&M or any other face to face service from the physician or group within the ...Acute Post-Operative Pain ManagementJanuary 4th, 2018 - Find-A-Code
CPT codes 62320, 62322 should be used when the analgesia is delivered by a single injection.These codes should only be used when the catheter or injection is not used for administration of anesthesia during the operative procedure. Modifier 59 should be used when billing these services to indicate that the catheter or injection was a ...Billing Negative Pressure Wound Therapy (NPWT) (disposable device)January 4th, 2018 - Find-A-Code
Per CMS: Disposable NPWT services are billed using the following Current Procedural Terminology® (CPT®) codes:
97607 - Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or ...Filing a CMS-1500 Claim form to Medicare PUB-100 184.108.40.206January 4th, 2018 - Find-A-Code
An independent clinical laboratory may file a paper claim form shall file Form CMS-1500 for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90.
An independent clinical laboratory that submits claims in paper format) may not combine non-referred (i.e., ...Modifiers 54-55, split surgical and postoperative careJanuary 4th, 2018 - Find-A-Code
54 -Surgical care only; Surgeon is performing only the preoperative and intra-operative care
55 - Postoperative management only; Physician, other than surgeon, assumes all or part of postoperative care
Modifiers should be placed on the surgical code
Used on 10 day and 90 day surgical procedures
Both the surgeon and the physician providing the postoperative ...Physical Therapist can now bill for a substitute Physical TherapistJanuary 4th, 2018 - Find-A-Code
As of 6/13/2017 Medicare contractors shall accept claims from Physical Therapists, Provider Specialty 65 – Physical Therapist in Private Practice, for services provided by a substitute physical therapist under a fee-for-time compensation arrangement when submitted with the Q6 modifier.
The A/B MAC Part B may pay the patient’s regular physician for physicians' ...