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09/10/21

eviCore Update for the State of Michigan

Per BCBS of Michigan, eviCore, beginning July 1, 2021, will no longer mail paper copies of the Practice Profile Summary, which includes information about your assigned category for outpatient physical therapy services, to health care providers. Instead, eviCore will post category updates on the first business day of February and August each year beginning in August 2021. Follow these steps to access your Practice Profile Summary and obtain your category: I hope you found this information helpful. Thank you for being a Gold Member!

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09/07/21

NCCI Edits Version 27.3 Effective October 1, 2021

The Centers for Medicare and Medicaid Services (CMS) has published the National Correct Coding Initiative (NCCI) edits, Version 27.3, for dates of service October 1, 2021 – December 31, 2021. These NCCI edits are not only used by traditional Medicare, but also by many state Medicaid and Managed Medicaid plans as well as many commercial insurance carriers and workers compensation insurance carriers. As Gawenda Seminars & Consulting (GSC) has done every quarter for their Gold Members, GSC has published their “cheat sheet” for the use of modifier 59 in outpatient therapy under NCCI edit Version 27.3. This “cheat sheet” includes

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08/23/21

Outpatient Therapy in the Home: FAQs

With an increase in private practices, especially solo practices, providing outpatient therapy in a patient’s home, I am receiving more and more questions regarding the regulatory, billing and payment rules. In addition, due to COVID-19, rehabilitation agencies and hospital outpatient therapy departments are sending their therapists to a patient’s home to provide outpatient therapy services. In this article, I will provide answers to the following questions: Does the Medicare program pay for outpatient therapy provided in a beneficiaries home? For Medicare purposes, what is considered a patient’s home? Do Medicare Advantage plans and commercial insurance carriers pay for outpatient therapy

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08/09/21

Medicare Advantage Plans: Frequently Asked Questions

There has been a lot of discussion on Medicare Advantage plans lately on several of the social media platforms. While social media can be a good place to seek information, the information that is shared is not always correct or perhaps, not correct for your specific situation and/or question. In this article, I will provide answers to the following questions I am routinely asked: Does the annual therapy threshold that applies to traditional Medicare beneficiaries also automatically apply to all Medicare Advantage plans and their beneficiaries? Does the 10th visit Progress Report that applies to traditional Medicare patients also apply

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08/02/21

Cigna and Ayres Sensory Integration® Coverage

Effective July 15, 2021, Cigna will now cover Ayres Sensory Integration for a diagnosis of Autism Spectrum Disorder. The criteria that must be met is detailed in their new policy. To access the policy, log into your Gold Member account and click I hope you found this article informative. Thank you for being a Gold Member!

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07/28/21

NGS Results of Reevaluation CPT Code Post-payment Review

National Government Services (NGS) has released the findings of their post-payment review they conducted on the physical therapy reevaluation CPT code, 97164 for the states of New York, Connecticut, Massachusetts, Maine, New Hampshire, Vermont and Rhode Island. The review focused on bill type 13X or 85X which means the claims selected were submitted by a hospital outpatient therapy department (bill type 13X) or a critical access hospital (bill type 85X). The results of this review provide a summary of claims with dates of service of 1/1/2019 through 2/28/2020 and do not include appeal results for overturns and decision reversals. Findings

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07/26/21

AIM Rehabilitative Program Site of Service Reviews Effective August 1, 2021

Effective August 1, 2021, AIM Specialty Health® (AIM), a separate company, will expand the AIM Rehabilitative program to perform medical necessity review of the requested site of service for physical, occupational and speech therapy procedures for Anthem fully-insured members. This site of service review will impact providers of therapy services in the following states: Connecticut Colorado Georgia Indiana Kentucky Missouri New Hampshire Nevada Ohio Per AIM, pre-certification I hope you found this article helpful to your therapy practice or department. Thank you for being a Gold Member!

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07/26/21

Hospice and Outpatient Therapy

Lately, I have been receiving questions via email and on various social media platforms concerning providing outpatient therapy services to a Medicare beneficiary who is in hospice. What people want to know is does the Medicare program pay a therapy provider separately for outpatient therapy services that they provide to a Medicare beneficiary who is in hospice? Let me answer this question for you as well as several other questions related to this topic. Question Does the Medicare program pay a therapy provider for outpatient therapy services that they provided to a Medicare beneficiary who is in hospice? Answer Question

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