"Medicare" & "Modifier Coding" Articles


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Cross-A-Code Instructions in Find-A-Code

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Cross-A-Code is a tool found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.

Medicare Improper Payment Report for Chiropractic (2019)

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CMS audits claims on an annual basis to identify improper payments. These improper payments do not measure fraud. Rather, they estimate the share of payments that did not meet Medicare coverage, coding, and billing rules. In the most recent Improper Payment Report by specialty, chiropractic has the highest Part B improper payment ...

Significant COVID-19 Code Changes as of October 6

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Significant COVID-19 Code Changes as of October 6

Coding Injections for Pain Management

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Coding for pain management can get confusing. How many injections, the location, and when to use a modifier are all common questions. This article will cover some of the most common injections used in pain management. Trigger Point Injections Trigger point injections are reported by how many muscles are treated using an ...

Modifier 50 — Four "Must Know" Tips For Getting Paid

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Modifiers added to an HCPCS or CPT© code alters the code description, providing clarity about the service for proper claim processing and reimbursement. Here are four things you must know about modifier 50 to ensure proper payment. - Modifiers are either informational or payment related. Informational modifiers provide additional...

Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately

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We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...

Are NCCI Edits and Modifiers Just for Medicare?

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The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that ...

Payment Adjustment Rules for Multiple Procedures and CCI Edits

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Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...

New ABN Form is Here

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The anticipated changes to the Advanced Beneficiary Notice of Non-coverage (ABN) Form (CMS-R-131) have arrived. This important form is issued to the patient or client by providers, physicians, practitioners, and suppliers in situations where Medicare payment is expected to be denied. You can begin using the new ABN immediately if you so wish. However, it becomes mandatory on August 31, 2020.

MEGA - NCCI Edit Changes - WHO Knew?

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There was no huge announcement when CMS released new files in April. The files that were released on April 7, 2020, actually replaced files to update the NCCI edits on Procedure to Procedure (PTP) edits and Medically Unlikely Edits (MUE).  The updated files included; 291,902 Deleted Procedure to Procedure (PTP) edits 197  Deleted Medically Unlikely ...

Changes in Medicare Advantage and Part D

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The Centers for Medicare & Medicaid Services finalized several changes in Medicare Advantage and Part D on Friday.  The Trump administration has finalized several changes in Medicare Advantage (MA) and Part D in anticipation of bid submissions on June 1. The Centers for Medicare & Medicaid Services (CMS) released  Friday that includes ...

Where is the CCI Edit with Modifier 25 on E/M?

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If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed.  The use of Modifier 25 is one example ...

Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?

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On April 10th, CMS released a memo with the subject line, “Applicability of diagnoses from telehealth services for risk adjustment,” suggesting there may be some telehealth services that might not qualify for risk adjustment. However, in the memo CMS states: “Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face ...

Additional Telehealth Changes Announced by CMS

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On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.

COVID-19 Chiropractic Resources

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COVID-19 Chiropractic Resources contains current, updated information regarding COVID-19. Included are lists of webinars, articles, websites and links pertaining to the ongoing changes.

More Telehealth Changes Announced by CMS Chiropractic Offices Should Know About

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On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). The announcement included far more information than is presented in this article which only summarizes the changes to telehealth. In fact, it does change a little of the information included in our March 31st webinar.

More Telehealth Changes Announced by CMS

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On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). See this article for further information as well as references & links to CMS information

CMS-Coverage for Therapeutic Shoes for Individuals with Diabetes

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Therapeutic shoes and inserts can play a vital role in a diabetic patient's health. Medicare may cover one pair every year and three pairs of custom inserts each calendar year if the patient qualifies and everything is handled correctly.  Medicare Benefit Policy Manual explains what is needed for a person with diabetes to ...

Providing Telehealth Services During COVID-19 Crisis

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The rules for providing telehealth services during this pandemic have changed and some requirements have been waived. Please keep in mind that “waiving requirements” does not mean that anything goes. Another important consideration is that Medicare and private payers may likely have different rules so you need to make sure that you know individual payer requirements during this time.

Medicare Part D Coverage Gap (Donut Hole) Closes in 2020

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Overview of the Part D coverage gap, how it got closed, what the picture looks like for 2020, and long-term outlook.

Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)

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The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...

Implementing Telehealth Visits

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The following is a step-by-step guide on how to convert office-based encounters to telehealth encounters during the current COVID-19 pandemic. These rules may change post-pandemic, as many changes relaxing existing rules were made on a temporary basis by CMS and commercial payers to facilitate patient access and minimize risk of infection. Step ...

Medicare Begins Covering Acupuncture Services

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Medicare is changing their policy regarding coverage of acupuncture, but in order to provide these services, you must follow their rules.

Medicare Announces Coverage of Acupuncture Services

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On January 21, 2020, a CMS Newsroom press-release read, This new announcement is both exciting and refreshing. Acupuncture, a key component of traditional Chinese medicine and most commonly used to treat pain, is now being officially recognized by Medicare and several other large payers as a covered, alternative treatment option for ...

Billing for Telemedicine in Chiropractic

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Many large private payers recognize the potential cost savings and improved health outcomes that telemedicine can help achieve, therefore they are often willing to cover it. While there are several considerations, there could be certain circumstances where telemedicine might apply to chiropractic care.

Denials due to MUE Usage - This May be Why!

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CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...

Medicare Changes Bilateral Reporting Rules for Certain Supplies

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DME suppliers must bill bilateral supplies with modifiers RT and LT on separate claim lines or they are being rejected.

Q/A: How do I Code a Procedure for the Primary Insurance so the Secondary Can Get Billed?

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Question: How do you modify a code submitted to the primary insurance company to let them know it is not covered by them so you can bill to a secondary?

Changes to Portable X-Ray Requirements

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On September 30, 2019, CMS published a final rule which made changes to portable x-ray services requirements as found in the law.

Medically Unlikely Edits (MUEs): Unlikely, But Not Always Impossible

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Medically Unlikely Edits (MUEs) were created by the Centers for Medicare & Medicaid Services (CMS) to help lower the error rate for paid Part B claims. MUEs are the maximum units of a HCPCS or CPT code that a provider would bill under most circumstances for the same patient on ...

CMS and HHS Tighten Enrollment Rules and Increase Penalties

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This ruling impacts what providers and suppliers are required to disclose to be considered eligible to participate in Medicare, Medicaid, and Children's Health Insurance Program (CHIP). The original proposed rule came out in 2016 and this final rule will go into effect on November 4, 2019.  There have been known problems ...

Vaccine Administration - When The Right Vaccine Code is Not Enough

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Understanding how to apply immunization administration codes properly will support correct reimbursement for vaccinations. Reporting the right vaccine code alone is not enough to guarantee proper billing. The majority of the time, providers can charge for the vaccine/product as well as the administration of the vaccine; always consult your payer ...

Q/A: How Do I Bill a House Call?

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Question If a provider makes a house call to/for a patient, is there a way that it is represented on the claim form?  A modifier, or something else? Answer Modifiers are not used to identify that a service was performed in the patient's home. However, other modifier rules must be followed (e.g., modifier GP ...

Are You Aware of Medicare Advantage Plans Timely Filing Rules?

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The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial. As any company who has billed Medicare services can attest, the one-year timely filing ...

Understanding Payment Indicators

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Understanding how payment works with Medicare payment indicators and the impact a modifier has on payment is vital to pricing. Even if you are not billing Medicare, most carriers follow Medicare's policies for participating and non-participating rules.  Here is an article from Regence on their policy statement, describing the rules ...

Q/A: I Billed 2 Units of L3020 and Claim was Denied. Why?

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Question: We billed 2 units of L3020 but were denied for not using the right modifiers. What should we do? Answer: Rather than submitting two units of the L3020 to indicate that the patient one orthotic for each foot, you would need to use modifiers identifying left foot and right foot. Appropriate coding ...

The OIG Work Plan: What Is It and Why Should I Care?

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The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...

The Slippery Slope For CDI Specialists

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Who knew that when Jack & Jill when up the hill to fetch a pail of water, they would have to ensure that in order to keep the level of water the same on the way back down, they would need to both support the pail.  Many of you in this industry are ...

Q/A: What do I Need to Document for Periodic Adjustments on a Medicare Patient?

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Question: What type of documentation is required for a Medicare patient with degenerative joint disease who get adjusted once or twice a month for occasional flare-ups of the D. J. D. region? The noted adjustments give good relief of the patient's symptoms. Answer: There is no question that these adjustments would be considered ...

Act Now on CMS Proposal to Cover Acupuncture for Chronic Low Back Pain

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Now is the time to comment on a proposal to cover acupuncture for chronic low back pain. This comment period is the part of the HHS response to the opioid crisis. You only have until August 14th to officially comment.

Q/A: Do I Use 7th Character A for all Sprain/Strain Care Until MMI?

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Question:  It is in regards to the Initial and Subsequent 7th digit (A and D) for sprains and strains. Recently, I have been told that I should continue with the A digit until the patient has reached Maximum Medical Improvement (MMI) and then switch over to the D place holder. Is ...

Helping Others Understand How to Apply Incident to Guidelines

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Over the past few months, I have worked with different organizations that have been misinterpreting the "incident to" guidelines and, in return, have been billing for services rendered by staff that are not qualified to perform the services per AMA and CPT. What I found within the variances is that ...

How to Properly Report Monitoring Patients Taking Blood-thinning Medications

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Codes 93792 and 93792, which were added effective January 1, 2019, have specific guidelines that need to be followed. This article provides some guidance and tips on properly reporting these services.

A United Approach

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A United Approach As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...

Q/A: For Physical Therapy Claims, What is the Correct Modifier Order?

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Question Page 116 of the 2019 ChiroCode Deskbook shows examples for Medicare modifiers. Is this the specific order for the modifiers to be entered? Our practice management software system is advising the GP or GY should be used as Modifier 1 and not as Mod 2 or Mod 3. Also, it shows the ...

Medicare Revises Their Appeals Process

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On April 12, 2019, Medicare announced that there will be some changes to their appeals process effective June 13, 2019. According to the MLN Matters release (see References), the following policy revisions in the Medicare Claims Processing Manual (MCPM), Chapter 29 are taking place: The policy on use of electronic signatures Timing ...

What is Medical Necessity and How Does Documentation Support It?

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We recently fielded the question, “What is medical necessity and how do I know if it's been met?" The AMA defines medical necessity as: It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...

Q/A: What do I do When a Medicare Patient Refuses to Sign an ABN?

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Question: What do I do when a Medicare patient refuses to sign an ABN? Answer: That depends on whether the patient is still demanding to have/receive the service/supply. If they aren’t demanding the service, then there is no need to force the issue. Just make sure that you still have an ...

Q/A: I Submitted a Claim to the VA and it’s Being Denied. Why?

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I submitted a claim to the VA and it’s being denied. Why? There are several reasons why your claim might be denied by the Veterans Administration (VA). However, without more information about the claim itself (e.g., services billed), we can only provide the following general information about the VA and chiropractic ...

Spinal Cord Stimulator Used for Chronic Pain

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Chronic pain is a condition that can be diagnosed on its own or diagnosed as a part of another condition. When coding chronic pain, there is no time frame defining when pain becomes chronic pain; the provider’s documentation should be used to guide the use of these codes. ICD-10-CM Diagnosis Codes ...

CPT Codes Exempt from Modifier 51 (Appendix E)

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The following CPT codes are exempt from the use of modifier 51.  These procedures are usually performed with another procedure, however, they may also be a stand-alone procedure.   17004 93456 93618 20697 93503 93631 20974 93600 94610 20975 93602 95905 31500 93603 95992 36620 93610 99151 44500 93612 99152 61007 93615 93451 93616 ...

CPT Codes That Should Not Be Reported With Modifier 63 (Appendix F)

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The following codes should not be reported with modifier 63. 30540 33946 46735 30545 33947 46740 31520 33978 46742 33470 33949 46744 33502 36415 47700 33503 36420 47701 33505 36450 49215 33506 36456 49491 33610 36460 49492 33611 36510 49495 33619 36660 46196 33647 39503 49600 33670 43313 49605 33690 43314 49606 33694 43520 49610 33730 43831 19611 33732 44055 53025 33735 44126 54000 33736 44127 54150 33750 44128 54160 33755 46070 63700 33762 46705 63702 33778 46715 63704 33786 46716 63706 33922 46730 65820 ...

Clearing Up Some Medicare Participation Misunderstandings

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Even though we may think we truly understand what it means to be a participating provider, Medicare doesn’t quite work the way that other insurance plans do. Far too many providers do not understand the difference and get into hot water. To further complicate matters, the rules are different for ...

The Impact of Medical Necessity on High Level E/M Services

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I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?"  The quick answer is, "it depends." Code 99233 has the following minimal component requirement: Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...

How to Report Imaging (X-Rays) of the Thumb

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If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. Anatomically, it is also referred to as the first phalanx (finger). However, when you are coding an x-ray of the thumb, images are captured of the thumb, hand, wrist, and all ...

Revised ABN Requirements Still Fuzzy

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Although it has been quite some time since ChiroCode published an article about the revised instructions for non-participating providers  who use the ABN, there are still some outstanding questions about this change. So far, Medicare has not provided additional guidance about this question despite requests by us for clarification. Medicare now requires non-participating providers to include the ...

Q/A: Can you Help me Understand the New Medicare Insurance Cards?

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As many of you are aware, CMS began issuing new Medicare identification cards last year which required the replacement of social security numbers with a new Medicare Beneficiary Identifier (MBI). All cards have now been mailed out and patient's should have the new cards when they come in. Currently, we are in the transition period until January 2020.

Billing Guidelines for Repositioning

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Code 95992 has some very limited payer payment guidelines which need to be understood for proper reimbursement. Many payer policies consider this service bundled with Evaluation and Management Services, therefore, it would not be separately payable if there was an E/M service performed on the same date. Some providers have reported having trouble ...

Understanding NCCI Edits

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Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...

Medicare Supplemental Policies (MediGap) and Extremity Adjustments

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The nice thing about MediGap policies is that they pay for some of the healthcare costs that an original Medicare plan (Part B) does not cover. So when a patient has Medicare and a Medicare supplement (MediGap) and their condition is related to an extremity (a noncovered service), Medicare must ...

Q/A: What's the Difference Between Q5 and Q6 for a Substitute Provider?

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It is important to understand that modifiers Q5 and Q6 are not interchangeable. So when do you use each of them?

Separately Report a "Separate Procedure" with Confidence

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Many procedures in the CPT® code book are designated "separate procedures," but that doesn't mean you can report those procedures separately in every case. First, you must consider other procedures performed during the same encounter.  "Separate" Might Not Mean What You Think It Does You can always identify a designated separate procedure by the inclusion of "(separate ...

Detection by Nucleic Acid (DNA or RNA) - Amplified Probe Technique

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This question was asked on the following lab codes used for testing during pregnancy. "Can the codes below be billed together?  87491- 59, 87591-59. 87081, 87150." YES- CPT code 87081 is used when a specific pathogen is suspected and is appropriate. YES- (X2) 87150 is used for culture, typing, and identification by nucleic ...

Coding Medicare Initial Preventive Physical Exams (IPPE)

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The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward. Purpose An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...

Q/A: Do Digital X-rays Have Their Own Codes?

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Question Are you aware if digital x-ray of the spine requires a different code than plain x-ray?  If so, where can I find the information specific to digital x-ray codes? Answer There are no separate codes for digital x-rays. However, there may be modifiers that are required to be submitted with the usual ...

Charging Missed Appointment Fees for Medicare Patients

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Some providers mistakenly think that they cannot bill a missed appointment fee for Medicare beneficiaries. You can, but Medicare has specific rules that must be followed. These rules are outlined in the Medicare Claims Policy Manual, Chapter 1, Section 30.3.13. You must have an official “Missed Appointment Policy” which is ...

Q/A: Can I Bill a Review of X-Rays?

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It is not unusual for a healthcare provider to review x-rays taken and professionally read by another entity. Questions arise regarding how to bill this second review. It is essential to keep in mind that the global (complete) service of taking an x-ray is composed of both a professional and ...

Physical Therapy Caps Q/A

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Question: How do I code it so that PT services in a chiropractic office don’t count against their PT visit max? Is there a way to code claims so that they are considered chiropractic only? But still get compensated enough? We have been running into some issues as of late ...

Attestations Teaching Physicians vs Split Shared Visits

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Physicians often use the term "attestation" to refer to any kind of statement they insert into a progress note for an encounter involving work by a resident, non-physician practitioner (NPP), or scribe. However, for compliance and documentation purposes, "attestation" has a specific meaning and there are distinct requirements for what ...

Empowering Medicare Beneficiaries

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BLOG: CMS announced a NEWS release today making it easier to help Medicare Beneficiaries access cost and quality information. CMS announced,  "Today, the Centers for Medicare & Medicaid Services (CMS) launched a new app that gives consumers a modernized Medicare experience with direct access on a mobile device to some of ...

Q/A: Which Code Should I Use for a Lab Interpretation Fee?

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Question Which code should I use for a lab interpretation fee? Specifically, I have ordered a female hormone saliva test, and would like to charge a fee for time spent on the interpretation and consult. Answer This type of service generally does not involve a third party, so it may be acceptable to ...

How to Report Co-Surgeons Using Modifier 62

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Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session. An easy way to explain this is to visualize a patient requiring cervical fusion where ...

Home Oxygen Therapy

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Home Oxygen Therapy Guidelines

CPT Modifiers 96 & 97 for Habilitative and Rehabilitative Services (2018-01-01)

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Effective January 1, 2018, CPT modifiers 96 "habilitative services" and 97 "rehabilitative services" will be in effect. There have been questions on whether modifier 96 will be preferred over HCPCS modifier SZ, which describes the same types of habilitative (but not rehabilitative) services, but payers have not yet indicated which modifier ...

AMA Issues new CMT Information

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As many of you may already be keenly aware, there have been ongoing problems with many payers (e.g., BCBS of Ohio) regarding the appropriateness of reporting an E/M visit on the same day as CMT (CLICK HERE to read article). The AMA recently released an FAQ which renders their opinion ...

Nine New Codes for Fine Needle Aspirations (FNA) in 2019

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If your practice performs a lot of fine needle aspirations (FNA), you probably have the code options memorized (10021 without image guidance and 10022 with image guidance). However, the 2019 CPT codes now include nine (9) new FNA codes (10004-10012), one deleted FNA code (10022) and one revised FNA code ...

Dry Needling

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The correct coding of dry needling, also known as trigger point needling, has been a subject of confusion for quite some time. The American Chiropractic Association (ACA) and the American Physical Therapy Association (APTA) have been working together for several years to obtain appropriate codes to describe this service. In ...

CMS Finalizes Major Changes to ACO Program

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Back in August of 2018, as part of the Medicare Shared Savings Program (Shared Savings Program), CMS proposed some sweeping changes for Accountable Care Organizations (ACOs). There has been some controversy over these changes which require ACOs to move to two-sided models. In this Final Rule which was scheduled to be published in the Federal Register ...


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