"Modifier Coding" & "CMS1500" Articles


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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...

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 ...

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 ...

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 ...

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.

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 ...

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?

Documentation Tips

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Documenting Medical NecessityTo receive reimbursement from medical insurers, you need to make a case that proves that dental surgery is necessary for the patient. To make your case, you need to explain your decision process in terms that a medical insurer can understand, using ICD-10 codes and CPT codes. These ...

And Then There Were Fees...

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Find-A-Code offers fees and pricing for just about everything, this article will address two of some of the most common payment systems with CMS. (OPPS) -Outpatient Medicare Outpatient Prospective Payment System. (MPFS)- Medicare Physician Fee Schedule The Fees section on each code page is determined on the type of services...

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 ...

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 ...

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 ...

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 ...

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.

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 ...

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 ...

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 ...

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 ...

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 ...

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 ...

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 ...


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