MODIFIER 59 AND SUBSET MODIFIER XE, XS, XP and XU

Posted on June 21, 2018 by kellyausiello

MODIFIER 59 AND SUBSET MODIFIER XE, XS, XP and XU

Modifiers are two-character suffixes (alpha and/or numeric) that are attached to a procedure code. CPT modifiers are defined by the American Medical Association (AMA). HCPCS Level II modifiers are defined by the Centers for Medicare and Medicaid Services (CMS) and provide a way to indicate that the service or procedure has been altered by some specific circumstance, but has not been changed in definition or code. Modifiers are intended to communicate specific information about a certain service or procedure that is not already contained in the code definition itself. Some examples are:

To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same surgery
To indicate that a procedure was performed bilaterally or to designate laterality (LT/RT)
To report multiple procedures performed at the same session by the same provider. • To report only the professional component or only the technical component of a procedure.
To designate performance on a specific part of the body (ie T3=L foot 4th digit.)

More than one modifier can be attached to a procedure code when applicable. Not all modifiers can be used with all procedure codes.

Modifiers do not ensure reimbursement. Some modifiers increase or decrease reimbursement; others are only informational but all are typically necessary to avoid denials.

Modifiers are not intended to be used to report services that are “similar” or “closely related” to a procedure code. If there is no code or combination of codes or modifier(s) to accurately report the service that was performed, provide written documentation and use the unlisted code closest to the section which resembles the type of service provided to report the service.

Modifier Definitions: Modifier 59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same day, see modifier 25.

Effective for dates of service January 1, 2015 and following, CMS established four new HCPCS modifiers to define subsets of the -59 modifier, to better define the “Distinct Procedural Service.” These modifiers are XE, XS, XP, and XU. (collectively referred to as -X{EPSU}. Where:

XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ or Structure
XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner
XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.

These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier and since The -X{EPSU} modifiers are more selective versions of the -59 modifier, it would be incorrect to include both the 59 modifier and a subset modifier on the same line.

Different Organs/Contiguous Structures:: From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example: Arthroscopic treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of a single anatomic site.”

Incorrect use of modifiers XE, XP, XS, XU, or 59:

Procedures in the same anatomical site (e.g. digit, breast, etc.), even with incision lengthening or contiguous incision.
CPT identified “separate” procedures performed in the same session, same anatomic site, or orifice. • Laparoscopic procedure converted to open procedure.
Incisional repairs are part of the global surgical package, including deliveries and cosmetic improvement of a previous scar at the location of the current incision.
Contiguous structures in the same anatomic site or organ system. (See Coding Guidelines “Different Organs/Contiguous Structures” and CCI Policy Manual, chapter 1.

**** Modifier XP should not be used to identify two providers of the same specialty in the same clinic to bypass global surgery package rules, new-patient visit edits, or other same-specialty rules.

Breathe A Little Easier Billing Nebulizer Treatments.

Posted on June 20, 2018 by kellyausiello

Coding for multiple nebulizer treatments is one of our “dual rule” issues where Medicare and other carriers who follow Medicare guidelines, differ from the AMA’s CPT™ instructions.

As of CPT 2016, CPT code 94640 describes treatment of acute airway obstruction with inhaled medication and/or the use of an inhalation treatment to induce sputum for diagnostic purposes. The language change was to clarify the intent that this be a “bundled code” representing both the diagnostic and therapeutic services. It does NOT however bundle multiple units.

According to the CPT™, when a patient receives multiple aerosol treatments on the same date, you should use 94640 for the first treatment and repeating subsequent treatments with the same code as a separate line item and adding require modifier 76 (Repeat procedure by same physician).

Therefore, you would code the example of two consecutive nebulizer treatments as:

94640–first treatment
94640-76 x 1 subsequent treatment.

For the inhalation solution, you should report two units of J7613 (Albuterol, inhalation solution, administered through DME, unit dose, 1 mg). Because J7613 represents one -unit dose.

A standard treatment session takes about 10 minutes and the patient should see some relief within 15 minutes. We understand from our physicians that one additional application is fairly common in the clinical setting especially in Urgent Care settings.

If a patient receives “back-to-back” nebulizer treatments exceeding 1 hour, (which rarely occurs in urgent care), you would bill CPT code 94644, “Continuous inhalation treatment with aerosol medication for acute airway obstruction; first hour,” and, if applicable, CPT code 94645, “Continuous inhalation treatment with aerosol medication for acute airway obstruction; each additional hour”, instead of CPT code 94640.

While CMS agrees with the rationale that code 94640 represents both the diagnostic and therapeutic services, they also ignore the AMA guidance and bundle multiple units.

Medicare: NCCI Policy Manual -2018; Chapter 11, J8. Page 26. CPT code 94640 (pressurized or non-pressurized inhalation treatment for acute airway obstruction…) describes either treatment of acute airway obstruction with inhaled medication or the use of an inhalation treatment to induce sputum for diagnostic purposes.

CPT code 94640 shall only be reported once during an episode of care regardless of the number of separate inhalation treatments that are administered. (Under Medicare regulations, an episode of care begins when a patient arrives at a facility for treatment and terminates when the patient leaves the facility.)

If CPT code 94640 is used for treatment of acute airway obstruction, spirometry measurements before and/or after the treatment(s) shall not be reported separately. The inhaled medication may be reported separately however, depending on the payer’s rules, the medication may also be bundled to the service.

The medications administered in the urgent care setting are most commonly a form of albuterol. You will find the correct codes to use in the “Healthcare Common Procedure Coding System Level II” (HCPCS) coding manual. Below is a list of Federal Drug Administration (FDA)-approved medication containing albuterol:

J7611, “Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, concentrated form, 1 mg”
J7612, “Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DEM, concentrated form, 0.5 mg”
J7613, “Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg”
J7614, “Levalbuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 0.5 mg”
J7620, “Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, FDA-approved final product, non-compounded, administered through DME”

There are several respiratory or pulmonary conditions that typically qualify for inhalation treatment coding, such as:

Asthma, (J45.-)
Acute bronchitis, (J20-)
Chronic obstructive pulmonary disease (COPD), (J44-)
Pneumonia, (J18.-)
Acute bronchospasm, (J98.01)
Cough, (R.05)
Wheezing, (R06.2)
Shortness of breath, (R06.02)

In summary, mark this code as having one unit billing for Medicare but multiple sessions to most major medical carriers. Remember to “justify” an additional session in your notes by showing incomplete relief from the first dose after a reasonable expected response time (ie 15-20 min).

CPT Modifiers 96 & 97 for Habilitative and Rehabilitative Services

Posted on May 23, 2018 by kellyausiello

Effective January 1, 2018, CPT modifiers 96 “habilitative services” and 97 “rehabilitative services” will be in effect for use. CMS deleted modifier SZ as of December 31, 2017 and added modifiers 96 and 97 to their edits.

(MLN Matters MM10385). 1/1/2018 — Add the following new modifiers to the valid modifier list;
– FY: Computed radiography x-ray
– JG: 340B Acquired Drug
– TB: Tracking 340b acquired drug
– X1: Continuous/broad services
– X2: Continuous/focused services
– X3: Episodic/broad services
– X4: Episodic/focused services
– X5: Svc req by another clinician
– 96: Habilitative services
– 97: Rehabilitative services

Private payers will probably adjust their policies to use the 96 and 97 modifiers as well, but you should confirm that with a benefits representative. The addition of a valid CPT modifier should NOT cause a reject and the new modifiers DO clarify your claim for the carrier.

The two new modifiers were created to identify services as habilitative or rehabilitative and made their appearance in the 2018 CPT™;

Modifier 96 Habilitative Services: When a service or procedure that may either be habilitative in nature or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified healthcare professional may add modifier 96- to the service or procedure code to indicate that the service or procedure provided was habilitative. Such services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep or improve those learned skills. Habilitative services also help an individual keep, learn, or improve skills and functioning for daily living.

Modifier 97 Rehabilitative Services: When a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified healthcare professional may add modifier 97- to the service or procedure code to indicate that the service or procedure provided was rehabilitative. Rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt, or disabled.

Simply put, rehabilitative services help patients restore functions or skills that have been lost, while habilitative services develop skills and functions that had not been developed previously.

Now that CMS has deleted modifier SZ in favor of the AMA’s 96 and 97, and naturally expect these modifiers to be reported with services such as physical medicine and rehabilitation codes allowing the payer the ability to differentiate habilitative from rehabilitative services.

This differentiation is required by the Patient Protection and Affordable Care Act.

Physical medicine and rehabilitative services are designed to improve, restore, or compensate for loss of physical functioning following disease, injury or loss of a body part which makes them an ideal ancillary inclusion for pain management and rehabilitation practices. Clinicians use the clinical history, systems review, physical examination, and a variety of evaluations to determine the impairments, functional limitations, and disabilities of the individual patient and then address them through design and implementation of a plan of care tailored to the specific needs of the individual patient. The services are not only beneficial for the patient but are a good source of revenue for the practice. Therapy service income often out performs other clinical services on a consistent basis.

Unfortunately, many multidisciplinary consultants are apparently uninformed on Medicare “requirements” on who can actually “perform” the therapy services and often misrepresent permissible delegation and the actual supervision requirements over unlicensed individuals in the physician’s office setting.

As a result, practitioners are learning the rules the hard way as a whistle blower, disgruntled employees or competitor reports prompt on site audits and recoveries in the hundreds of thousands of dollars.

The premise for therapy is based on patients who must have a potential for restoration or improvement of lost functions and require the services of a skilled therapist. Rehabilitation services are typically short term, intensive and have clear goals for services employed to restore and maintain a level of function. Naturally Medicare patients are often subjected to illnesses and conditions effectively treated with physical therapy rehabilitation efforts.
Under Medicare policies, intervention with PM&R modalities and procedures is indicated when:

• an assessment by a physician, NPP or therapist supports utilization of the intervention,
• there is documentation of objective physical and functional limitations (signs and symptoms), and
• the written plan of care incorporates those treatment elements that require services of a skilled therapist for a reasonable and generally predictable period of time.

Skilled therapist; for Medicare reimbursement means that the covered therapy services were “personally performed by one of the following individuals;

• Licensed therapy professionals: licensed physical therapists and occupational therapists
• Licensed PTA with appropriate supervision by a licensed physical therapist.
• Licensed occupational therapy assistants (OTA) with appropriate supervision by a licensed occupational therapist.
• Medical Doctors (MDs) and Doctors of Osteopathy (DOs).
• Doctors of Optometry (ODs) and Podiatric Medicine (DPMs) when performing services within their licenses’ scope of practice and their training and competency.
• Qualified NPPs, including Advanced Nurse Practitioners (ANPs), Physician Assistants (PAs) or Clinical Nurse Specialists (CNS) when performing services within their licenses’ scope of practice and their training and competency (ANP, PA, CNS).
• “Qualified” personnel when appropriately supervised by a physician (MD, DO, OD, DPM) or qualified NPP, and when all conditions of billing services “incident to” a physician have been met.
o Qualified personnel providing physical therapy (PT) or occupational therapy (OT) services “incident to” the services of a physician/NPP must have met the educational and degree requirements of a licensed therapy professional (PT, OT) from an accredited PT/OT curriculum, but are not required to be licensed. (Otherwise called an “unlicensed graduate PT/OT”).

There always seems to be some “consultants” who spend more time advising their clients on possible ways to “beat the system” than educating them on how to do things properly and avoid potential conflicts with regulations. Knowledgeable consultants know that reimbursement for skilled services have an included calculated component based on the amount of “professional” time required to render the service to the patient. You may have noticed this “little requirement” in the description of various “time based” therapy codes where the language clearly states “one-on-one patient contact by provider”.

In my opinion, it is completely illogical for any provider to expect a carrier to pay for professional time when the services were provided by “trained aides” who lack the comprehensive training necessary to exercise professional judgment over the therapy or procedure.

The Federal programs for example, draw fairly clear lines on who is and who is not qualified to receive reimbursement for “professional time” by reviewing Medicare regulations 230.1(C) and 230.2(C) which clearly state;

Services provided by aides, even if under the supervision of a therapist, are NOT therapy services in the outpatient setting and are NOT covered by Medicare.

Although an aide may help the therapist by providing unskilled services, those services that are unskilled are not covered by Medicare and shall be denied as not reasonable and necessary if they are billed as therapy services.

Services of athletic trainers, massage therapists, recreation therapists, kinesio-therapists, low vision specialists or any other profession may not be billed as therapy services.
• This includes service performed by Chiropractors since Medicare will not pay for any service performed, ordered or supervised by a Chiropractor.

In short, Medicare will not pay for the services of a “qualified provider” unless the services are performed by a “qualified provider”. Learn the difference and apply the principles.

QUALIFIED PROFESSIONAL means a physical therapist, occupational therapist, speech-language pathologist, physician, nurse practitioner, clinical nurse specialist, or physician’s assistant, who is licensed or certified by the state to perform therapy services, and who also may appropriately perform therapy services under Medicare policies.

Qualified professionals may also include physical therapist assistants (PTA) and occupational therapy assistants (OTA) when working under the supervision of a qualified therapist, within the scope of practice allowed by state law.
Assistants may not supervise others.

QUALIFIED PERSONNEL means staff (auxiliary personnel) who may or may not be licensed as therapists but who meet all of the requirements for therapists with the exception of licensure. Qualified personnel have been educated and trained as therapists and qualify to furnish therapy services under direct supervision and incident to a physician or NPP.

So next time, your so-called consultant wants you to bill the services of a med tech under your provider number, remember;

Fraud, as defined by Federal Regulation (42CFR455.2) , is an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in the payment of unauthorized benefits. A scheme does not have to be successful to be considered fraudulent.

Abuse involves actions that are inconsistent with sound medical, business, or fiscal practices. Abuse, directly or indirectly, results in higher costs to the healthcare program through improper payments that are not medically necessary. (under the carrier’s published policy).

The primary difference between fraud and abuse is a person’s intent. That is, did they know they were committing a crime?
In either case, the key component is that the perpetrator knew or should have known that the act was improper and under the revised false claims act you could face the possibility of treble damages and civil penalties of up to $11,000 for each improper claim and full membership in the exclusive OIG’s excluded individuals club !

Therapy Claims for 2018 and beyond for Medicare.

Posted on April 20, 2018 by kellyausiello

After decades of monitoring the annual Medicare therapy caps and temporary exceptions fiascos, I got an early morning call from a Washington DC friend contact that Congress had finally “repealed” the cap on therapy services.

It was well into the early morning hours when the Senate finally voted 71-28 to pass a budget bill known as the Bipartisan Budget Act of 2018 .

I knew word would spread fast and my phone would soon start ringing so I quickly reviewed the bill’s language and found we still had a cap at $2010 but it had been changed back to a “soft” cap and the exception process missing from the previous legislation in January, had now been provided.

Section 50202 – Repeal of Medicare Payment Cap for Therapy Services; Limitation to Ensure Appropriate Therapy – The new law requires for services after December 31, 2017:
* Medicare claims are no longer subject to the therapy caps (one for occupational therapy services and another for physical therapy and speech-language pathology combined);
* Claims for therapy services above $2010, the same amount as the previous therapy caps, must include the KX modifier indicating that such services are medically necessary as justified by appropriate medical record documentation; and
* Claims for therapy services above $3,000 of incurred expenses may be subject to targeted medical review.

So, the threat of a hard cap is gone and Medicare beneficiaries can still obtain necessary therapy services beyond the $2,010 limit as long as you affix the KX modifier to the claim.

Discipline Modifiers:
CMS also implemented a requirement for billing therapy services by ANY PROVIDER. (MM101076) effective 1/1/2018 set an additional billing requirement for any “always therapy” service provided by any provider specialty type. The instruction informed all providers that each code designated as “always therapy” must always be submitted with one of the therapy discipline modifiers GN, GO or GP in addition to any other relevant payment modifier like the KX modifier.

Based on this policy change, even a chiropractor providing an always therapy service must append the appropriate therapy modifier (normally GP) for the service being billed IN ADDITION TO modifier GY to indicate the service is non-covered by Medicare for their provider type.

Many Chiropractic offices are having claims “rejected” by CMS rather than being “denied and forwarded” to the secondary insurance just because they did not append the default GP discipline modifier to the therapy line items.

A rejected claim does NOT PROCESS through the system at all and therefore does not generate a valid denial for purposes of collection from the patient or their secondary coverage carrier. Offices that are not following the new reporting requirements have found themselves in a revolving door of re-submissions.

If, on any claim from any provider, one of the therapy modifiers, GN, GO or GP, is not appended then the claim will reject and not process through the Medicare processing system for denial.

You will need to refile the claim with the appropriate modifiers for it to process for denial.

The last battle: To offset future costs associated with eliminating the hard cap, Congress also enacted a payment differential for PTAs and COTAs like that used for Physician Assistants and Nurse Practitioners, which means therapist assistants will be reimbursed 85% of the amount PTs and OTs receive for the same services.

This reduction is set to go into effect on January 1, 2022 and will have more impact on “facilities and rehab agencies” than the Part “B” office setting where direct supervision of an enrolled PT or OT is required.

Baring any legislative actions to the contrary, we should be firmly set on the issues of caps and exceptions until the end of 2027.

CPT code 64555 Abuse it, lose it!

Posted on September 18, 2017 by kellyausiello

Many of you probably remember our repeated objections to sales organizations advising their purchasers to bill code 64555 (percutaneous implant of neurostimulator array; neuromuscular for ariculo-therapy procedures.

We have been advising against this billing since it first was reviewed in 2013 and published our correct coding opinion as being either 64999 or more specifically;

HCPCS: Is the Most specific.

S8930 Electrical stimulation of auricular acupuncture points; each 15 minutes of personal one-on-one contact with the patient.
- (Developed and became effective April 1, 2012.

The 2018 CPT has removed the temptation for these improper billing by deleting the 64555 code entirely and adding a parenthetical note stating “For percutaneous electric neuromuscular stimulation or neuromodulation using needle(s) or needle electode(s) [eg PENS, PNT,] use 64999.

We hope this will finally put this matter to rest.

Moderate Sedation – 2017

Posted on April 27, 2017April 27, 2017 by kellyausiello

References: CR10001 – Medicare Claims Processing Manual – Pub 100-04 Chapter 12, Sections 50 and 140. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

Effective May 15, 2017 CMS revises their manual to bring it in line with current payment policy for moderate sedation and other anesthesia services in light of the CPT changes for January 1, 2017.

Anesthesia services range in complexity from least to the most complex as follows:

local or topical anesthesia,
moderate (conscious) sedation,
regional anesthesia and
general anesthesia.

General Payment Rule:

The fee schedule amount for physician anesthesia services furnished is typically based on the allowable base and time units multiplied by an anesthesia conversion factor specific to the geographic locality and communicated to the MACs by means of the annual updates to the Healthcare Common Procedure Coding System (HCPCS) file. The base units and conversion factor are available at https://www.cms.gov/Center/Provider-Type/Anesthesiologists-Center.html

Moderate sedation is a drug induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation but does not include minimal sedation, deep sedation or monitored anesthesia care. Practitioners are instructed to report the appropriate CPT and/or HCPCS code that accurately describes the moderate sedation services performed during a patient encounter, which are performed in conjunction with and in support of a procedural service, consistent with CPT™[1] guidance.

CPT codes 99143-99150 previously used for reporting moderate sedation were deleted from CPT 2017™ and replaced with;

NEW 99151	Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; initial 15 minutes of intraservice time, patient younger than 5 years of age
99152	initial 15 minutes of intraservice time, patient age 5 years or older
99153	each additional 15 minutes intraservice time (List separately in addition to code for primary service) [Regardless of age of patient.]
99155	Moderate sedation services provided by a physician or other qualified health care professional other than the physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports; initial 15 minutes of intraservice time, patient younger than 5 years of age
99156	initial 15 minutes of intraservice time, patient age 5 years or older
99157	each additional 15 minutes intraservice time (List separately in addition to code for primary service)

According to the AMA guidelines,

Preservice activities required for moderate sedation are included in the work described by each code 99151-99157 and are not reported separately.

Intraservice time:

is used to determine the appropriate CPT code to report moderate sedation services:

Begins at the administration of the sedating agent(s);
Ends when the procedure is completed, the patient is stable for recovery status, and the physician or other qualified healthcare professional providing the sedation and personal continuous face-to-face time with the patient;
Includes ordering and/or administering the initial and subsequent doses of sedating agents;
Requires continuous face-to-face attendance of the physician or other qualified healthcare professional;
Requires monitoring patient response to the sedating agents, including:
- Periodic assessment of the patient;
- Further administration of agent(s) as needed to maintain sedation; and
- Monitoring of oxygen saturation, heart rate, and blood pressure

Intraservice time of less than 10 minutes should NOT be reported.

If the physician or other qualified healthcare professional who provides the sedation services also performs the procedure supported by sedation (99151, 99152, 99153), the physician or other qualified healthcare professional will supervise and direct an independent trained observer who will assist in monitoring the patient’s level of consciousness and physiological status throughout the procedure.

An independent trained observer is defined as an individual who is qualified to monitor the patient during the procedure and who has no other duties during the procedure.

Postservice Work

The postservice activities required for moderate sedation are included in the work described by each code 99151-99157 and are not reported separately.

If the physician performing the medical or surgical procedure also provides a level of anesthesia lower in intensity than moderate or conscious sedation, such as a local or topical anesthesia, then the conscious sedation code should not be reported and no payment should be allowed by the A/B MAC (B). There is no CPT code for the performance of local anesthesia and as payment for this service is considered in the payment for the underlying medical or surgical service.

[1] CPT is a registered trademark of the American Medical Association, used with permission.

2017 CPT will expand Therapy Evaluation Codes.

Posted on July 8, 2016 by kellyausiello

For CY 2017, the CPT Editorial Panel will deleted four CPT codes (97001, 97002, 97003, and 97004) and create eight new CPT codes (97X61-97X68) to describe the evaluation procedures furnished by physical therapists and occupational therapists. There are three new codes, stratified by complexity, to replace a single code, 97001, for physical therapy (PT) evaluation, three new codes, also stratified by complexity, to replace a single code, 97003, for occupational therapy (OT) evaluation, and one new code each to replace the reevaluation codes for physical and occupational therapy – 97002 and 97004.

Here is an advanced look at the requirements……

New CPT Code/ CPT Long Descriptors for Physical Medicine and Rehabilitation
97X61 Physical therapy evaluation: low complexity, requiring these components:
● A history with no personal factors and/or comorbidities that impact the plan of care;
● An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
● A clinical presentation with stable and/or uncomplicated characteristics; and
● Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 20 minutes are spent face-to-face with the patient and/or family.

97X62 Physical therapy evaluation: moderate complexity, requiring these components:
● A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
● An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following body structures and functions, activity limitations, and/or participation restrictions;
● An evolving clinical presentation with changing characteristics; and
● Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 30 minutes are spent face-to-face with the patient and/or family

97X63 Physical therapy evaluation: high complexity, requiring these components:
● A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
● A clinical presentation with unstable and unpredictable characteristics; and
Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
Typically, 45 minutes are spent face-to-face with the patient and/or family.

97X64 Reevaluation of physical therapy established plan of care, requiring these components:
● An examination including a review of history and use of standardized tests and measures is required;
and
● Revised plan of care using a standardized patient assessment instrument and/or measurable assessment
of functional outcome
Typically, 20 minutes are spent face-to-face with the patient and/or family.

97X65 Occupational therapy evaluation, low complexity, requiring these components:
● An occupational profile and medical and therapy history, which includes a brief history including
review of medical and/or therapy records relating to the presenting problem;
● An assessment(s) that identifies 1-3 performance deficits (ie, relating to physical, cognitive, or
psychosocial skills) that result in activity limitations and/or participation restrictions; and
● Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (eg, physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.
Typically, 30 minutes are spent face-to-face with the patient and/or family.

97X66 Occupational therapy evaluation, moderate complexity, requiring these components:
● An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance;
● An assessment(s) that identifies 3-5 performance deficits (ie, relating to physical, cognitive, or
psychosocial skills) that result in activity limitations and/or participation restrictions; and
● Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
Typically, 45 minutes are spent face-to-face with the patient and/or family.

97X67 Occupational therapy evaluation, high complexity, requiring these components:
● An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance;
● An assessment(s) that identify 5 or more performance deficits (ie, relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
● A clinical decision-making is of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (eg, physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.
Typically, 60 minutes are spent face-to-face with the patient and/or family.

97X68 Reevaluation of occupational therapy established plan of care, requiring these components:
● An assessment of changes in patient functional or medical status with revised plan of care;
● An update to the initial occupational profile to reflect changes in condition or environment that affect
future interventions and/or goals; and
● A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.
Typically, 30 minutes are spent face-to-face with the patient and/or family

The changes are shown in CMS proposed plan for 2017.

The real risk of carrier audits!

Posted on February 6, 2016February 6, 2016 by kellyausiello

Let’s face it, many practices are having a hard time staying profitable and may engage in some “creative billings” to increase what they are paid by various carriers. For some reason, practices seem to think that Medicare/ Medicaid/ and Tricare are their only real concerns when it comes to misrepresenting services for financial gain.

Typically their first concern arises when they receive a letter from an investigations unit requesting several patient files for specific dates of service that the carrier bases on their provider participation agreement authorizing the plan(s) to perform reviews, audits and statistically valid sampling techniques for peer review program activities, medical necessity reviews, data validation reviews, billing and claims payment audits, coding or quality review audits; all of which routinely hold all physicians in the practice jointly and severally liable for misreporting by any and all providers in the practice.

Healthcare fraud is a crime under most criminal codes and consists of intentional deceit within the healthcare system for the purpose of illicit gains. Healthcare abuse is similar activity or behavior where knowing intent to obtain an unlawful gain cannot be established.
The primary difference between fraud and abuse is a person’s intent. That is, did they know they were committing a crime? In either case, the key component is that the perpetrator knew or should have known that the act was improper or inconsistent with sound practices.

It’s important to distinguish health care fraud from mere mistakes, omissions, or improper payments. To commit fraud, a person must knowingly engage in a plan, scheme, or activity to provide falsehoods or misrepresentations with the intent to achieve some financial gain.

The proof of the allegations is the existence of the claims regardless of the payment or denial. The scheme does not need to be successful to be considered fraudulent.

Most practices referred by the carrier for criminal actions are due to intentional misrepresentation of the procedure performed and willful misconduct by the providers, managers and billing people to mis-code the actual service(s) and falsify the medical records to support the misrepresented service codes. The “collaboration” of the parties to the scheme is usually prima facie evidence of intent and the testimony of one of the more innocent collaborators who rolls over on the boss, is all it takes to prove intentional fraud.

Stealth Coding.
The “basic instructions” on code selection contained in the CPT®* manual prohibits “stealth” coding.
“Select the name of the procedure or service that accurately identifies the service performed. Do not select a CPT code that merely approximates the service provided. If no such specific code exists, then report the service using the appropriate unlisted procedure or service code. ………When necessary, any modifying or extenuating circumstances are added. Any service or procedure should be adequately documented in the medical record.”

Conservative estimates of the amount of healthcare expenditures lost to fraud is three percent of total services paid, which equates to over $70 billion annually. Frequently seen examples are;

• Billing for more expensive services or procedures than were actually provided or performed, commonly known as “upcoding”-i.e., falsely billing for a higher-priced treatment than was actually provided. This is often combined with an accompanying “inflation” of the patient’s diagnosis code to a more serious condition consistent with the false procedure code.
• Performing medically unnecessary services solely for the purpose of generating insurance payments-seen very often in nerve-conduction and other diagnostic-testing schemes.
• Misrepresenting non-covered treatments as medically necessary covered treatments for purposes of obtaining insurance payments- This is often seen in multidisciplinary settings where a non-covered service such as spinal manipulation or extremity adjustments by a Chiropractor are represented as a covered physical therapy procedures under order of a medical provider.
• Falsifying a patient’s diagnosis to justify tests, surgeries or other procedures that aren’t medically necessary.
The majority of health care fraud is committed by a very small minority of dishonest health care providers.

Sadly, the actions of these deceitful few ultimately serve to sully the reputation of perhaps the most trusted and respected members of our society-our physicians. Unfortunately these fraud-doers take advantage of the confidence that has been entrusted to them in order to commit ongoing fraud on a very broad scale and their ability to spread false billings among many insurers simultaneously including public programs such as Medicare and Medicaid, where they can maximize fraud proceeds while lessening their chances of being detected by any a single insurer.

Federal Criminal False Claims Statutes (18 U.S.C. §§ 287,1001) Section 1001 applies to anyone whose action(s) related to any claim(s) for government payment consist(s) of any of the following:
• Falsifying, concealing, or covering up by any trick, scheme or device a material fact related to any claim(s) for government payment;
• Making any materially false, fictitious or fraudulent statement or representation; • Making or using any false writing or document knowing it contains any materially false, fictitious or fraudulent statement or entry.
Section 287 states that whoever makes or presents to the government a claim knowing that it is false, fictitious or fraudulent shall be imprisoned and subject to fines.
We understand from attorneys that the government is required to establish all of the following in regard to the action(s) of a false claim(s) case defendant. He/she:
• Made or presented a false, fictitious or fraudulent claim to a department of the United States;
• Knew the claim was false, fictitious or fraudulent; and
• Did so with the specific intent to violate the law or with awareness that what s/he was doing was wrong.

EMPLOYEES BEWARE: Bosses are not doing their employees any favors when the intimidate them to “do as they are told”. Filing false and miscoded claims can seem like a minor crime, but a conviction for health care fraud, especially when the defendant is a professional who depends on a license to practice, can irreparably change the course of that professional’s life. “My boss made me do it” is normally NOT going to get you absolve you of your participation in perpetrating the crime or conspiracy to cover it up.

As carriers improve investigative techniques through their National Health Care Anti-Fraud Association and refer more cases for criminal action in addition to recovering their money, we need to offer the following advice to our members;
The moment you are approached by investigators about a potential fraud case, you need to contact a criminal defense attorney. You can unknowingly incriminate yourself anytime you speak to an investigator if you don’t have legal advice. Local criminal defense attorneys are the only people capable of providing you with legal advice in light of their knowledge of the law, as well as their experience with local prosecutors, courts, and criminal investigations.

If you’re being investigated for breaking a federal law, your case will be handled in the federal court system. Be sure that the lawyer you choose has experience handling federal cases.

Naturally the best defense is to do it right in the first place.
If you are unsure of a particular billing scenario or you get a “I get paid doing this” from a “friend”, Contact us! Your Academy is here to help you.

*CPT is a registered trademark of the American Medical Association- gratefully used with their permission.

Modifier 59 Subsets, “CMS separates the separate and distinct modifier”

Posted on May 18, 2015 by kellyausiello

Modifier “59” “Distinct Procedural Service” is probably one of our most widely used and most frequently abused coding modifiers.

The modifier was created to identify a wide variety of circumstances and exceptions that qualify additional services for separate payment such as different encounters; different anatomic sites; or distinct additional services by bypassing the established NCCI edits so the additional work of both the primary and the additional procedures will be paid.

NCCI edits are in place to prevent unbundling of services where one code is considered to be a subset of the work of another code billed on the same claim. This sets the column 1/ column 2 scenario of the NCCI where edits define when two codes should not be reported together and also assigns a “Correct Coding Modifier Indicator” (CCMI) for exceptions.

A CCMI of “0” indicates that the codes never be reported together by the same provider for the same beneficiary on the same date of service. They are considered mutually exclusive and therefore the column 1 code would be eligible for payment but the column 2 code is not.

A CCMI of “1” however indicates that the codes “may be reported together” only when the defined circumstances are such that what would be normally considered an overlapping service was actually separate and distinct and independent of the other services performed.

Most carriers increase scrutiny of the modifier in “manual reviews” since the use of the modifier will typically bypass the automated “front end” edits by the claims processing software. The modifier has long been identified as one of considerable abuse and since it is “very broad” in its application, manual reviews of its use frequently result in denials and even allegations against the provider of fraud and abuse.

CMS has established four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to identify specific circumstances as subset replacements of the -59 modifier.

XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

Patients returning for a separate encounter on the same DOS are rare in the office setting. This would be used for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed during different patient encounters on the same day and that cannot be described by one of the more specific NCCI-associated modifiers – i.e., 24, 25, 27, 57, 58, 78, 79, or 91.

XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ or Structure,

One of the common uses of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed at different anatomic sites, are not ordinarily performed or encountered on the same day, and that cannot be described by one of the more specific anatomic NCCI-associated modifiers – i.e., RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI.

XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner

XU Unusual Non-Overlapping Service, A Service That Is Distinct Because It Does Not Overlap Usual Components of The Main Service.

CMS originally set an “effective date” of January 1, 2015 however they have also declared that the modifiers are valid even before national edits are in place.

MACs are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier, when necessitated by local program integrity and compliance needs. In short, that means that while CMS will continue to recognize the -59 modifier in many instances, the MAC may selectively require a more specific – X{EPSU} modifier for billing certain codes at high risk for incorrect billing. Check your MAC’s policies frequently.

You should also check your major medical carriers for changes to the more descriptive modifiers. United Health care published in their network bulletin in January, 2015 that they were following the CMS lead and would accept either but NOT BOTH on the same line item.

In the CMS release they stated: “The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a -59 modifier or a more selective – X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.”

If the carrier accepts the new subsets, you may find them beneficial on your multiple injections or to establish that a therapy such as 97140 was administered to a separate anatomical region.

You should use one or the other. You should NOT report both the 59 and one of the X* modifiers on the same line item.

The CR (CR8863) to the Carriers is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1422OTN.pdf

The Future of Viscosupplementation for OA of the knee with the “Blues”

Posted on April 3, 2015August 10, 2015 by kellyausiello

BLUES NEW POSITION STATEMENT: “Intra-articular hyaluronan injections are associated with clinically irrelevant benefit and an increased risk of adverse events; therefore, are considered not medically necessary.”

Effective April 1, 2015 several of the “Blues” such as Florida Blue[1] and BCBSWNY[2] (Healthnow) took the lead for the “Blues” in taking unprecedented actions against paying for Intra-articular hyaluronan injections of the knee as a treatment for pain caused by osteoarthritis of the knee. Continue reading “The Future of Viscosupplementation for OA of the knee with the “Blues”” →