Select the title to see a summary and a link to the full article.
October 4th, 2021
Watch out for New ICD-10-CM Codes
By Wyn Staheli, Director of Research | Published October 4th, 2021
New ICD Codes for: Low Back Pain, Cervicogenic Headache, Non-Radiographic Axial Spondyloarthritis (nr-axSpA), and Social Determinations of Health (SDOH). These codes became effective on October 1, 2021.
Stay out of Trouble — Understand the Qualified Medicare Beneficiary (QMB) Program
By Wyn Staheli, Director of Research | Published October 7th, 2020
To assist low-income Medicare beneficiaries, CMS created the Qualified Medicare Beneficiary (QMB) program; a Medicaid benefit which pays for Medicare deductibles, coinsurance, or copays for any Medicare-covered items and services for Medicare Part A, Part B, and Medicare Advantage (Part C). Providers/suppliers are prohibited from billing premiums and cost sharing to Medicare beneficiaries who are enrolled in QMB.
Use the Correct Diagnosis Codes and Revenue Codes to Get Paid for PAD Rehab
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 15th, 2020
The initial treatment in rehabilitation for patients suffering from Intermittent Claudication (IC) is Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). Rehabilitation using SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest.
When reporting 93668 for peripheral arterial disease rehabilitation the following ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 14th, 2020
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 ...
ICD-10-CM Official Coding and Reporting Guidelines Updated for COVID-19
By Wyn Staheli, Director of Research | Published April 8th, 2020
The ICD-10-CM Official Coding and Reporting Guidelines have just been updated to include COVID reporting. Additional information beyond the previously released interim guidelines are included. These are the rules that should be followed for claims submission. The notice states that this is for April 1, 2020 through September 30, 2020.
CMS-Coverage for Therapeutic Shoes for Individuals with Diabetes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 31st, 2020
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 ...
New Biofeedback Codes to replace 90911 Eff 2020-01-01
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 26th, 2020
CMS announced 90912 and 90913 are to be used starting January 2020 in place of 90911.
According to CMS MLN, these new codes, designated as “sometimes therapy”, are reported to furnish these services outside a therapy plan of care when appropriate.
Codes are permitted to be used by physicians and Non-Physician Practitioners (NPPs), ...
By Namas | Published August 16th, 2019 - Last Review/Update August 20th, 2019
Medical ID Theft
"So, do you guys think you can do something with that?" John asked angrily at our first meeting with him in August 2017 as he slammed a stack of medical bills, EOBs and collection letters - three inches high - down in front of my partner and I. ...
The OIG Work Plan: What Is It and Why Should I Care?
By Namas | Published August 9th, 2019 - Last Review/Update August 14th, 2019
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 ...
Act Now on CMS Proposal to Cover Acupuncture for Chronic Low Back Pain
By Wyn Staheli, Director of Research | Published July 17th, 2019
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.
By BC Advantage | Published July 12th, 2019 - Last Review/Update July 30th, 2019
Last year was historic for HIPAA enforcement. The HHS Office of Civil Rights collected a record $23.5 million in settlements and judgments against providers guilty of HIPAA violations. To avoid becoming part of that unwanted statistic, it’s important to pay extra close attention to five key areas of HIPAA vulnerability.
Take ...
Will the New Low Level Laser Therapy Code Solve Your Billing Issues?
By Wyn Staheli, Director of Research | Published July 8th, 2019
Low level laser therapy (LLLT), also known as cold laser therapy, is a form of phototherapy which uses a device that produces laser beam wavelengths, typically between 600 and 1000 nm and watts from 5–500 milliwatts (mW). It is often used to treat the following:
Inflammatory conditions (e.g., Rheumatoid Arthritis, Carpal ...
Electrical Stimulation and Electromagnetic Therapy Devices
By Raquel Shumway | Published May 13th, 2019 - Last Review/Update May 20th, 2019
Electrical Stimulation and Electromagnetic Therapy Devices can be used for pain, muscle atrophy, help spinal cord injuries, treat symptoms caused by other medical conditions and can be used in the treatment of wounds. This Regence BC/BS article lists codes and devices and gives guidance on coding from Medicare Advantage viewpoint.
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 5th, 2019
State scope of practice laws and regulations will help determine who is considered Clinical staff and Other qualified Health Care professionals.
Physician or other qualified healthcare professionals: Must have a State license, education training showing qualifications as well as facility privileges.
Examples of Qualified Healthcare professionals:
(NOTE: this list is not all-inclusive, please refer to your payer ...
By Wyn Staheli, Director of Research | Published February 1st, 2019 - Last Review/Update February 4th, 2019
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 ...
Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...
By Wyn Staheli, Director of Research | Published October 16th, 2018
Pelvic floor dysfunction is often the underlying cause of conditions such as pelvic pain; urinary or bowel dysfunction; and/or sexual symptoms. Treatment generally begins with an evaluation and testing (e.g, EMG) followed by a variety of services (e.g., biofeedback, manipulation, pelvic floor electrical stimulation), depending on the findings.
Coverage by payers ...
By Wyn Staheli, Director of Research | Published August 16th, 2018 - Last Review/Update January 30th, 2019
Are there any alternative procedure codes for billing mechanical massage (e.g., muscle master vibromassage, genie rub, etc)? I know that 'by the book' mechanical devices are not covered under 97124, but wondered if you have suggested a go-around code.
By ChiroCode | Published June 20th, 2018 - Last Review/Update January 30th, 2019
Question
The code, 97124, Is specifically for massage but I have read that Insurance will more likely pay for 97140. Could we bill for whichever one pays? I believe that we have to indicate which area is used for CMT and which area for massage. Is it enough to document that ...
Q/A: Can a PT Assistant Perform Physical Therapy Modalities?
By Wyn Staheli, Director of Research | Published June 18th, 2018 - Last Review/Update January 30th, 2019
Whether or not a physical therapy assistant (PTA) may perform physical therapy modalities depends on two factors: state law and payer policies. Read here for more.
When is 97112 Neuromuscular Re-education Billable?
By Dr. Evan Gwilliam, VP for PayDC | Published March 13th, 2018 - Last Review/Update January 31st, 2019
Q: I just received a note from an attorney regarding a patient who was rear ended about 40 mph and ended up with neuropathy in her upper and lower extremities. We treated her for about 3 months after previous care failed to give much relief. I used flexion distraction and deep muscle stimulation to break up adhesions from the injury and used the 97112 code of neuromuscular re-education. The insurance company said that code was not warranted for her spinal sprain diagnosis and denied all of the services. Do you know how I could justify it? It greatly improved her condition with each visit and the patient said we provided the greatest relief she received.
Medicare Requiring Specific Modifiers on Therapy Services
By Wyn Staheli, Director of Research | Published January 15th, 2018
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 ...
By Wyn Staheli, Director of Research | Published January 15th, 2018 - Last Review/Update January 30th, 2019
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?
Should ROM Testing be Reported with Evaluation and Management Services?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 9th, 2018
Reporting the performance of range of motion testing (95851-95852) at the same encounter of an Evaluation and Management (EM) service, produces an NCCI edit resulting in payment for the EM service and denial of the ROM testing. Read the article to learn what other codes ROM testing is considered incidental to.
According to CGS Administrators, qualified professionals may serve as clinical instructors for therapy students within their scope of practice. Physical therapist assistants and occupational therapy assistants may only serve as clinical instructors for physical therapist assistant students and occupational therapy assistant students, respectively, when performed under the direction and supervision ...
According to CGS Administrators, most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment.
97032 is a constant attendance electrical stimulation modality ...
According to CGS Administrators, for initial evaluations, PTs shall use code 97161-97163 and OTs shall use code 97164-97167. Physicians and other qualified non-physician providers should use the evaluation and management codes 99201-99350 for evaluations.Consider the following points when billing for an evaluation.
These evaluation codes are untimed, billable as one unit.
Do ...
According to CGS Administrators, the reevaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment, or terminating services. Reevaluation provides additional objective information not included in other documentation, such as treatment or progress notes.Reevaluations are distinct from therapy ...
According to CGS Administrators, CPT codes 97012, 97016, 97018, 97022, 97024, 97026, and 97028 require supervision by the qualified professional/auxiliary personnel of the patient during the intervention.
CPT codes 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes ...
According to CGS Administrators, the objective of these treatments is to cause vasodilation and relieve pain from muscle spasm. Because heating is accomplished without physical contact between the modality and the skin, it can be used even if skin is abraded, as long as there is no significant edema.Diathermy achieves ...
According to CGS Administrators, therapeutic ultrasound is a deep heating modality that produces a sound wave of 0.8 to
3.0 MHz. In the human body ultrasound has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone may receive ...
According to CGS Administrators, hydrotherapy involves the patient’s immersion in a tank of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions.Qualified professional/auxiliary personnel one-on-one supervision of the patient is required. If the level of care does not require the skills of ...
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 ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 12th, 2017
The exact level of the subluxation must be specified in the documentation to substantiate payment of a claim.
You may document the exact bones such as C3, C3 or the area if it implies only certain bones such as the Occipito-atlantal - Occiput, and C1 (Atlas).
C1 is the first vertebra known as the atlas. The axis-form is ...
By David Klein CPC, CPMA, CHC | Published October 31st, 2017 - Last Review/Update February 5th, 2019
Recent events regarding delegation of services to ancillary personnel have given rise to concerns regarding the delivery of outpatient physical medicine by Chiropractors, specifically regarding the appropriate use of one-on-one codes as opposed to group therapy code CPT 97150 - Therapeutic procedure(s), group (2 or more individuals). This advisory provides guidance on how to properly use one-on-one and group therapy codes, both independently and together.
Speech-Language Pathology Services Policy from UniCare
By Find-A-Code | Published October 27th, 2017
Medically Necessary:
Rehabilitative speech-language pathology (SLP) services are considered medically necessary when ALL of the following criteria are met:
The services are used in the treatment of communication impairment or swallowing disorders resulting from illness*, injury, surgery, or congenital abnormality; and
Based on a plan of care, the therapy sessions achieve a specific ...
By ChiroCode | Published August 17th, 2017 - Last Review/Update January 31st, 2019
Watch this short video, "Secrets of 97140 Manual Therapy," to learn all that you need to know about the proper support for 97140.
ChiroCode_DeskBook_Tips_97140 from Innoventrum on Vimeo.
...
Delegation to Staff is not Allowed. Can I Bill for Group Exercises if I Supervise?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published August 8th, 2017 - Last Review/Update February 5th, 2019
My state does not allow me to delegate the supervision of therapeutic exercises (97110). I am the licensed chiropractor. If I provide the constant attendance myself, can I do it for a group of patients? If so, how do I document and bill for this?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 4th, 2017
We can look forward to a few prospective payments for Skilled Nursing Facilities, Hospice and Inpatient Rehab; CMS released their final rule and reported on key highlights of the new FY 2018 Medicare payment rules.
CMS States, “The 2018 Skilled Nursing Facility (SNF) Prospective Payment System Final Rule increases Medicare payment rates ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 13th, 2017 - Last Review/Update July 26th, 2017
Medical review decisions are based on the information submitted in the medical record. Therefore, it is critical that the medical record information submitted is accurate and complete to allow medical review to make a fair payment decision. The medical record information submitted should:
Paint a picture of the patient’s impairments and ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 20th, 2017 - Last Review/Update July 28th, 2017
The Local Coverage Determination (LCD) for Outpatient Physical and Occupational Therapy Services describes the coverage limits of outpatient physical and occupational therapy services under Medicare Part B. It's billed to either the Medicare Fiscal Intermediary (FI) or Part A or Medicare Carrier or Part B MAC when services are provided ...
Are There any Alternatives for Code 97112 Neuromuscular Re-education?
By ChiroCode | Published March 24th, 2017 - Last Review/Update January 31st, 2019
Q: Are there any alternatives for code 97112 Neuromuscular Re-education? This code is counted toward both Chiropractic and Physical Therapy visits with BCBS, and we want to preserve the insurance benefits.
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 1st, 2017 - Last Review/Update July 28th, 2017
Multi-layered, sustained, graduated, high compression bandage systems are used primarily to treat lymphedema and venous or stasis leg ulcers. A number of graduated, high-compression bandage systems products have been developed, including Profore®, Dyna-Flex®, Surepress®, Setopress®, and other similar product systems.Providers should note that the treatment of lymphedema with the application ...
By ChiroCode | Published January 13th, 2017 - Last Review/Update January 31st, 2019
Whiplash Damages in Rear-end Collisions - The Patient’s Dilemma:
The rear-end collision is a major cause of cervical spine injuries which often require treatment by chiropractors and other health care practitioners. Claims adjusters trivialize soft tissue injuries [it’s “only” a sprain or strain] but whiplash is real and so are the damages that come with it.
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2015
Documentation Requirements for Therapy Services, indicates that the amount of time for each specific intervention/modality provided to the patient is not required to be documented in the Treatment Note. However, the total number of timed minutes must be documented. These examples indicate how to count the appropriate number of units ...
Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2015 - Last Review/Update August 7th, 2017
Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech - language pathology services. They should never be used with codes that are not on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy ...
By | Published October 22nd, 2014 - Last Review/Update January 27th, 2017
Is it appropriate to use 97022, whirlpool, to report dry hydromassage?
The CPT code 97022 is defined simply as “Application of a modality to 1 or more areas; whirlpool”. The CPT book does not expand on the code. However, in 2002, the CPT manual added this phrase to the general guidelines:
Do ...
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