Finding Our Path

By Jenifer J. Ausiello, DNP, APRN, AGNP-C, ACHPN, CPC, CPMA

Several years ago, I was working as a Nurse Practitioner in a hospital setting for an amazing Infectious Disease practice. The doctor I worked with was known to be one of the best in the city. He was in high demand and therefore, I had to work hard to support him. My typical day consisted of working 16+ hours at the hospital rounding on patients and several hours of charting at home afterward most days. I was making ok money, but it was a fraction of what my boss was collecting for my services. I knew I was worth more than I was being paid, AND with the hours I was putting in, I had no time left for a personal life.


Luckily, I met my wife at the hospital. She was a nurse on the oncology floor working 12-hour days. We met and fell in love at the hospital and most of our time together was spent there, during our shifts. Had it just been the two of us, this may have an acceptable lifestyle for us. Something to note here is that we each brought 4 children into the relationship. Yes, you heard me correctly. We had a total of 8 children. My future wife and I quickly realized that spending more time together, and with our growing family was the most important thing to us both. We wanted more time together, outside the hospital.


Since my checks were dependent upon the money I brought into the practice each month, I knew I couldn’t decrease my work hours without taking a pay cut. I was struggling with how to spend more time at home and still support this new family. I was torn between supporting my boss / making the money we needed to pay the bills and spending more time at home / trying to figure out where the money would come from.


As contract re-negotiation approached at work, I started taking stock of my contribution to the company. I knew the care I provided to the patients was excellent and that my visits were uncaptured revenue for my boss. He was physically unable to see the number of patients we had each day. Without me there, he would be missing out on all that revenue. So, I went into the negotiation, planning to ask for a larger percentage of my collections, something we had already been talking about the year prior when the company structure had changed. Of course, the plans had gone by the wayside, as often happens in busy practices. But now was my time! I was ready to stand up for what I was worth. I presented them with what I felt was a fair value for my services. I listened to the counteroffer, and stood there, floored… They wanted me to take a pay cut! I wanted to quit right then and there. I could not believe it. I did not have a Plan B in place, so I stayed. But I spent weeks agonizing over how I could make and keep the money I worked for and spend more time with my family.


Not many people know this, and my wife will tell you all about it complete with reenactments and impersonations if given the chance, but I am compelled to do math when I am uncertain about financial matters. I love to figure out the numbers and make sense of choices in front of me. I knew the reimbursement rates for my hospital visits and decided to look up reimbursement rates for office visits and home visits. I figured out that if I was able to keep all the money collected for my own visits, I would be able to make the same money with less than half the number of visits I was currently doing in the hospital! My wife and I decided right then that we would open our own practice for the home-bound elderly and disabled population, and everything changed.


My wife was able to quit her job and work full time on starting our business and return to school. I was able to transition to a part time position elsewhere while we grew our practice. We still had to deal with the long hours of hard work, but we were in it together. In the end, we were starting on the journey that would land us here, helping others get and keep the money they deserve for their hard work.


“As every practitioner has figured out, it is nearly impossible to understand what these insurance companies require, what they will cover, and yet at the same time, they have almost complete control over our livelihoods, over our confidence in the care we provide, and even over our mental health!”

Our Story

  • Where we started
  • The struggle is real
  • Carrying a legacy
  • What we can do for you

Our Origin Story 

By Jenifer Ausiello, DNP, APRN, AGNP-C, ACHPN, CPC, CPMA

A few years back, my wife and I decided to open our own primary care practice. I am a nurse practitioner and my wife is in school to be a nurse practitioner. We both specialize in adult and elderly patients. We felt strongly that the disabled/elderly population were disadvantaged, especially those who did not have the mobility or assistance to go to a traditional medical office. We thought to ourselves, as many often do upon starting a new adventure…This is going to be great! We found our niche and decided to specialize in doing home visits for the homebound patient population.


Let’s be honest, no one wants to work for someone else. Our dream was to be entrepreneurs and be our own boss. Our goal was to build the practice to a point that we could make the jump from our other jobs and support our family on our own. Eventually, we wanted to be able to hire other providers and support staff and have the business be a consistent source of passive income and expand our services to more people.


At this point in time, I was struggling with the realities of how time consuming it was to provide quality care to my patients. We were working 18+ hour days to make sure our patients had everything they needed. We received most of our patients from Home Health Care Agency referrals. We were buried in paperwork. The phrase “caught up” was laughable. But we couldn’t afford to slow down. Our patients and referring agencies wanted for nothing, but we were miserable. All time together was working time, and all conversations revolved around patient care. There was no balance between work and home life. It was ruining our marriage and our general happiness. That made me feel like a failure, not just in my relationship but in my ability to provide for my family and to run a successful business. But what else were we going to do? All businesses go through this right? Just keep working. So, we kept plugging along.


Then one night, as I was charting on the visits from the previous day, signing orders, checking emails, etc. I stopped to open the mail. I was always excited to see the payor envelopes because it is more money! “I like checks!” is kind of my motto. But this night, I opened the envelope expecting that check, ready to do my mental math and figure out how much profit we had made to date, when I saw it. The bold font title of the letter, “Request for Repayment”. The panic that ensued lasted days, even weeks. I read every line of the letter and just could not understand how this could happen. I was physically unable to do anything for days. I could only seek out information about what I was going through. The panic and anxiety overtook me, and I spent every waking moment worrying and searching for information about how this could happen and what it means. Things got worse when I realized this could lead to a full-blown audit! I knew, or thought I knew, that we worked ourselves to the bone making sure our patients were well cared for in every way. Yet, none of it mattered to the insurance company. As every practitioner has figured out, it is nearly impossible to understand what these insurance companies require, what they will cover, and yet at the same time, they have almost complete control over our livelihoods as practitioners, over our confidence in the care we provide, and even over our mental health!

Along with the panic I was already feeling regarding audits, fear regarding future denials, and other possible repayments set in, the self-doubt followed, and I felt like giving up entirely. Like I was going to have to resign myself to keeping my “real job”, give up entrepreneurship, and be doomed to work for someone else for the REST OF MY LIFE.


I should mention that my wife is constantly telling me that everything happens for a reason. Because this next part is where it gets interesting. My wife received a phone call regarding her father’s health, and everything changed. My father-in-law and my wife had been estranged for many years. So, when I met him for the first time, it was in his hospital room. One of the first things he said to me was “I think you’d be perfect to take over the company”. I had no idea at the time what he was talking about, but he had been running his own compliance consulting business for 30+ years and had planned for my wife to take it over when he retired. He helped numerous medical practices and their attorneys with lawsuits and compliance issues. He conducted internal audits for practices and provided education on everything from patient intake to proper coding and billing of visits. His expertise and leadership was essential to the startup and continued success of his clients. So, we talked it over and decided the legacy should live on through us as he had always wanted. There wasn’t much time to get this accomplished, so the next several months consisted of “crash course” on the job training mixed with intense studies. We learned as much as we could from him but also poured over regulations and insurance company provider handbooks, contracts, and policies day and night. We sought out intensive training programs from the industry leaders. After an immense amount of work and training, my wife and I were certified as professional coders and professional medical auditors.


During this process, my father in law deteriorated quickly. We spent copious amounts of time with him daily for months, which eventually led to him living in our home for the final week of his life. In the end, he and my wife were closer than they had ever been, we learned invaluable knowledge, and he passed feeling confident that his legacy was in good hands.


Here is where my wife gets to hear that she is right. Things played out the way they did for a reason. This journey has allowed me to understand exactly why I got that Notice of Repayment letter and how I could not only avoid future repayments but also, how to avoid denials and welcome audits. This meant we could also use this knowledge to help other providers avoid these anxiety invoking moments too… BEFORE they happen. In the end, the information we learned and the tools we have now allow us to bill for the time we spend caring for our patients and get paid without the worry of denials, audits, or repayment letters.


A new passion was also born. So many of our fellow healthcare practitioners are going through the same things that we have encountered, but without the knowledge that we now have. I think you will agree that the majority of us got into this line of work to help people. But healthcare is a business with very tight purse strings. With all of the different mechanisms of recoupment activity, all the types of audits and companies working on behalf of insurance companies to take money back from providers, it’s just a matter of time before you will become the target.


Our Company MediCorp Compliance Solutions allows us to help other practitioners avoid the sleepless nights and bill with confidence for the excellent care they provide. And in the end, this has allowed us to be right where we want to be, getting paid what we are worth and with more time to spend with our growing family and allows us to help others do the same.



Auditors have identified frequent compliance issues with providers of all disciplines reporting of CPT code 97110; Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility.

The new audit probe will focus on; medical necessity, correct billing of timed codes and relationship to other therapy codes provided under same POC.

We offer the following Documentation Guidance to help you receive a Successful Review for your Outpatient therapy CPT Code(s) 97110

  • Physical and/or occupational therapy initial evaluation
    • Diagnosis and description of problem being evaluated
    • Objective, measurable current functional status
    • Subjective patient self-report of status
    • Clinician’s clinical judgments that describes the patient’s status
    • Determination of the need for treatment
    • Documentation to support the services require the skills of a therapist
  • Advance Beneficiary Notice of Non-Coverage (ABN), if applicable
  • Physician certification and recertification of the therapy plan of care
  • Physical and/or occupational therapy plan of care
    • Diagnoses
    • Long term measurable treatment goals
    • Type, amount, duration and frequency of therapy services
  • Physical and/or occupational therapy progress reports
    • Written by a clinician – not an assistant.
    • Minimum progress reports are every 10 treatment days
    • Assessment of patient progress towards goals
    • Plans for continuing treatment
    • Changes to goals
  • Physical and/or occupational daily treatment notes
  • Physical and/or occupational therapy treatment log
    • Total time spent for each modality billed
  • Physical and/or occupational therapy re-evaluation(s) as necessary
  • Physical and/or occupational therapy discharge note
  • Any additional documentation needed to support Medicare guidelines

We remind you that your total units of therapy being billed are constrained by your total therapy time and subject to the “8 minute” rules on individual therapy line items.

Under typical interpretation of time standards, you should not bill for any daily therapy (one unit total for the day) if it is less than 8 minutes however some carriers “may permit” billing of one unit for “modalities” greater than 5 minutes. Most however, will consider the service to be “incidental” to some other primary procedure for that day and not pay separately for the additional service.

For any single code, reported without any additional therapy services, providers should bill a single 15 minute unit for treatment greater than or equal to 8 minutes and less than 23 minutes.

If the duration of the single modality or procedure is greater than or equal to 23 minutes and less than 38 minutes, then two (2) units are billed.

Time intervals for larger numbers of units are as follows:

3 units > 38 minutes to < 53 minutes
4 units > 53 minutes to < 68 minutes
5 units > 68 to < 83 minutes
6 units > 83 minutes to < 98 minutes

The schedule shown above is intended to assist you in rounding time into 15 minute increments. It does not imply that any minute until the 8th should be excluded from the total count as the timing of active treatment counted includes all active therapy time.

It is not appropriate to count all minutes of treatment in a day toward the units for one code if other services were also performed for more than 15 minutes. Regardless of what some consultants may recommend, if you perform therapeutic exercises (97110) for 15 minutes and massage (97124) for 15 minutes you should report one unit of each service and not combine the times to two units under either code especially to receive a higher reimbursement OR to hide it where NCCI or non-coverage edits would preclude payment.

If however, any 15 minute timed service is performed for 7 minutes or less on the same day as another 15 minute timed service that was also performed for 7 minutes or less, the total time of the two combined is 8 minutes or greater. In this case you would legitimately bill “one unit for the service performed for the most minutes”. Your documentation will show the actual services in support of the billing.

Good Luck !


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.

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).

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 !

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.

There have been several “issues” caused by the changes in billing Medicare for 2018. Many practices, including Chiropractic offices are now having claims “rejected” by CMS rather than being “denied and forwarded” to the secondary insurance.

A rejected claim does NOT PROCESS through the system at all and therefore is NOT 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.

Chiropractic Office Issues: You all know that Medicare policy states a chiropractor should bill any service they provide that is not covered by Medicare for their specialty with modifier GY to receive a formal denial of the service and, when possible, have the denial forwarded to the patient’s secondary carrier for payment. This was proper UNTIL 2018 when there was a change to this process FOR ALL PROVIDER TYPES that may have been overlooked.

CMS implemented a change (MM101076) effective 1/1/2018 for always therapy services that contained an additional billing requirement for any always therapy service provided by any provider specialty type.

All providers were informed that each code designated as “always therapy” must always be accompanied by one of the therapy modifiers GN, GO or GP in addition to any other relevant payment modifier.

What you need to do:
Based on this policy change, all providers, including 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.

If one of the therapy modifiers, GP,GO or GN, is not appended then the claim will reject and not process through the Medicare processing system AT ALL.

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

Medical offices will encounter a CO 4 denial ” The procedure code is inconsistent with the modifier used or a required modifier is missing”  with a MA130 remark “Your claim contains incomplete and/or invalid information and no appeal rights are afforded because the claim is unprocessable.  Please submit a new claim with the correct information”

Again, the ruling applies to ALL PROVIDERS who bill therapy services to Medicare.

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.


Can I Treat My Partner’s Mother and Bill Medicare?

By R.L. “Ron” Ramsdell, PhD, FACFEI, DABFE, CFC, LFMAAMA.

The regulations on treating immediate relatives are found in the Medicare Benefits Policy Manual, Pub 100-02 in Chapter 16 (General Exclusions From Coverage) Section 130.  To better understand these regulations, you must first be familiar with the definitions of “provider and supplier” as used in all Medicare regulations.

Provider is defined at 42 CFR §400.202 and generally means a hospital, critical access hospital, skilled nursing facility, comprehensive outpatient rehabilitation facility, home health agency or hospice, that has in effect an agreement to participate in Medicare; or a clinic, rehabilitation agency, or public health agency that has in effect a similar agreement but only to furnish outpatient physical therapy or speech pathology services; or a community mental health center that has in effect a similar agreement but only to furnish partial hospitalization services.

Supplier is also defined in 42 CFR §400.202 and means a physician or other practitioner, or an entity other than a provider that furnishes health care services under Medicare.

In general, Medicare excludes payment for services rendered by a physician or other practitioner not only to their own immediate relatives but also to relatives of the owner or owner’s of the practice entity. (130-A.)

The intent of this exclusion is to bar Medicare payment for items and services that would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge. This exclusion applies to items and services rendered by providers to immediate relatives of the owner(s) of the provider. It also applies to services rendered by physicians to their immediate relatives and items furnished by suppliers to immediate relatives of the owner(s) of the supplier.”.

 Immediate Relative, as defined in regulations includes;

  • Husband and wife;
  • Natural or adoptive parent, child, and sibling;
  • Stepparent, stepchild, stepbrother, and stepsister;
  • Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in-law;
  • Grandparent and grandchild; and
  • Spouse of grandparent and grandchild.

There are some minor exceptions but basically these prohibitions also survive divorce or death of the actual relative.  In a stated example within the regulations, (130 B.) we see;

“For example, if a provider treats the stepfather of the owner after the death of the owner’s natural mother or after the owner’s stepfather and natural mother are divorced, or if the provider treats the owner’s father-in-law or mother-in-law after the death of their spouse, the services are considered to have been furnished to an immediate relative, and therefore, are excluded from coverage.”

Current regulations also extend to “members of the patient’s household” who share a single family unit dwelling and includes their (live in) domestic employees.

 “These are persons sharing a common abode with the patient as a part of a single family unit, including those related by blood, marriage or adoption, domestic employees and others who live together as part of a single family unit. A mere roomer or boarder is not included.”

The prohibition of payment for services rendered to the immediate relatives is quite broad and applies whether the provider or supplier is a sole proprietor or a partnership in which even “one of the partners” is related to the Medicare patient and extends to any “incident to” services that may be provided by a nurse or technician.(130 E)

What if my PA or NP treats the relative?

Under Medicare regulations, 130 F, “This exclusion applies to charges imposed by a non-physician supplier that is not incorporated, whether the supplier is owned by a sole proprietor who has an excluded relationship to the patient, or by a partnership in which even one of the partners is related.”

Under regulation 130 D, Regulations state;  “Professional corporation means a corporation that is completely owed by one or more physicians, and is operated for the purpose of conducting the practice of medicine, osteopathy, dentistry, podiatry, optometry, or chiropractic, or is owned by other health care professionals as authorized by State law. Any physician or group of physicians which is incorporated constitutes a professional corporation.”

 The regulations provide an “exception” for the stockholders, officers or directors of a corporation (other than a professional corporation) however you should definitely check with a competent healthcare law attorney for a legal opinion on how your “particular corporation” would actually be viewed under the Medicare rules.

Summary: The Medicare regulations would appear to prohibit your billing for services rendered to your partner’s mother or any other immediate relative of any partner within your practice.  I would suggest you refer the patient to a physician that is not associated with your practice or provide the care at no cost to anyone.

 The discussion presented above is offered only as an overview of Medicare regulations and is not intended to be, or construed by the reader as being a legal opinion or legal advice.  Private carrier policies may vary in coverage on this subject.  While the author has made a good faith attempt to present the discussion accurately, the discussions presented are base on lay-interpretation of the issues and should not be viewed as an attempt to offer or render legal advice or opinion or otherwise engage in the practice of law.  The discussion presented is, at best, of a general nature and cannot be substituted for the advice of a licensed attorney at law with specialized knowledge in healthcare regulatory issues.
 The M.A.A.M.A. and the Medcorp Compliance Network always advise physicians and other practitioners to seek the advice and legal opinion of a licensed healthcare law attorney in your home State as your only authoritative interpretation of all matters of law and regulation for Federal, State and individual carrier coverage issues.