Private practices and institutional settings (i.e. hospitals, SNF’s, Rehab Agencies, CORF’s and Home Health Agencies) may be providing 60 days of uncompensated outpatient therapy services and not even realize it. This is due to a provision in the Affordable Care Act (ACA) called the ‘grace period”. Here is how it works.

With approximately 15 million Medicare beneficiaries enrolled in Medicare Advantage plans under Medicare Part C, I am often asked if the Medicare Advantage plans follow the same rules as traditional Medicare for outpatient therapy services in terms of Functional Limitation Reporting, the application of the Multiple Procedure Payment Reduction policy, PQRS for private practices, CCI edits and the use of modifier-59, using the therapy specific modifiers (i.e. GN, GO, GP), and the application of the Medicare therapy cap, just to name a few. While Medicare Advantage plans must follow certain federal guidelines, they are offered by private insurance carriers such

If you are a physical therapist, occupational therapist, or speech-language pathologist in private practice and you treated and billed Medicare beneficiaries in calendar year 2012, keep on reading. The Centers for Medicare and Medicaid Services (CMS), in an effort to promote transparency, has published Medicare provider utilization and payment data on physicians as well as physical therapists, occupational therapists and speech-language pathologists in private practice. The CMS look-up tool will return information on services and procedures provided to Medicare beneficiaries, including utilization information, payment amounts (allowed amount and Medicare payment), and submitted charges organized by Healthcare Common Procedure Coding System

The Centers for Medicare and Medicaid Services has issued a booklet explaining the Medicare enrollment process and claim submission guidelines. The information in this publication applies only to the Medicare Fee-For-Service Program. Information discussed in the booklet includes: enrolling in the Medicare program, submission of Medicare claims including timely filing requirements, deductibles, coinsurance and deductibles, beneficiary notices of noncoverage, billing requirements, and claim processing. To access the booklet, click

UnitedHealthcare Medicare Solutions has announced they have

The Centers for Medicare and Medicaid Services (CMS) have issued instructions in changes to the Reopening process for non-private practices (i.e. institutional settings). These changes were necessary due to a non-standard approach of requesting a Reopening from one Medicare Administrative Contractor (MAC) to another. In an effort to streamline and standardize the requesting process, CMS has petitioned the National Uniform Billing Committee (NUBC) for a “new” bill type frequency code that can be used by providers to indicate a Request for Reopening and a series of Condition Codes that can be utilized to identify the type of Reopening being requested.

The Centers for Medicare and Medicaid Services (CMS) has issued a special publication that alerts providers that a major reason for claims being denied is failure to obtain certification and recertification statements from physicians or NPPs. The routine admission order established by a physician is not a certification of the necessity for post hospital extended care services for purposes of the program. Your therapy and billing staff needs to be aware of the requirements outlined below of what is an acceptable certification statement, what is an acceptable recertification statement, and how and when to document the certification and recertification statements.

The Centers for Medicare and Medicaid Services (CMS) is establishing four new Healthcare Common Procedure Coding System (HCPCS) modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.” 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. Because it can be so broadly applied, some providers incorrectly consider it to be the “modifier to use to bypass National Correct Coding Initiative (NCCI)”, it is the most widely used modifier.