Currently, providers can use the -59 modifier to indicate that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. The primary issue associated with the -59 modifier is that it is defined for use in a wide variety of circumstances, such as a use to identify different encounters, different anatomic sites, and distinct services. Usage to identify a separate encounter is infrequent and usually correct; usage to define a separate anatomic site is less common and problematic; usage to define a distinct service is common and

Modifier 59 is used in the outpatient therapy setting to identify when one intervention was provided at a separate and distinct time from another intervention by one discipline to the same Medicare beneficiary during the same treatment session or same date of service when multiple disciplines treat the Medicare patient within the same organization (non-private practice setting or incident-to-physician). Modifier 59 is not only the most commonly used modifier, but is also the most abused modifier that is utilized. Due to this, the Centers for Medicare and Medicaid Services (CMS) has defined four new HCPCS modifiers to selectively identify subsets

On October 1, 2015 health systems across the country transitioned to the International Classification of Diseases, 10th Revision – ICD-10. This change will enable providers to capture more details about the health status of their patients to improve patient care and public health surveillance. The Centers for Medicare and Medicaid Services (CMS) has been carefully monitoring the transition and is pleased to report that claims are processing normally. Generally speaking, Medicare claims take several days to be processed and, once processed, Medicare must– by law – wait two weeks before issuing a payment.   Medicaid claims can take up to 30

The Centers for Medicare and Medicaid Services (CMS) has issued updated policies concerning exceptions to the annual therapy caps due to medical necessity. These policies will only apply when the exceptions process is in effect. CMS reiterates that a Medicare beneficiary may qualify for use of the cap exceptions process at any time during the episode when documented medically necessary services exceed caps. All covered and medically necessary services qualify for exceptions to caps. There are no longer diagnosis codes that automatically qualify a Medicare beneficiary for an exception to the annual therapy cap dollar threshold. This has been true

With the recent transition to ICD-10, you may wonder how soon you will know whether your Medicare fee-for-service (FFS) claim was paid. Generally speaking, Medicare FFS claims take several days to be processed and must also – by law – wait two weeks before payment is issued. The Centers for Medicare and Medicaid Services has 5 different options how you can check the status of your claims. You can check your Medicare FFS claim status by:

One of the most common questions I receive is when a 7th character is required on an ICD-10 code, how do I know if the 7th character should be the character “D” or character “S”? The use of the 7th character, in my opinion, is one of the most confusing for physical and occupational therapists as well as speech-language pathologists to understand. Below, I will answer the question of when to use “D” or “S” when a 7th character is required. If the reason for therapy is a result of an injury and the ICD-10 code requires a 7th character

Beginning with dates of service on and after January 1, 2016, the Centers for Medicare and Medicaid Services (CMS) will begin applying the therapy cap limits to hospitals in the state of Maryland. Up until then, the therapy cap limits do not apply to hospitals in Maryland since they are not paid under the Medicare Physician Fee Schedule, but rather, the Maryland All-Payer Model. To read the detailed update, click

In mid-January 2015, CMS approved the Recovery Auditors to begin reviewing Outpatient Therapy Threshold claims (those over the $3700 threshold) that were paid March 1, 2014 through December 31, 2014. In an effort to minimize provider burden, CMS set restrictions on the number of Additional Documentation Requests (ADRs) that could be sent related to these claims, as shown below.