In this article, I will explain the 4 sets of modifiers that could be applicable to the advance beneficiary notice of non-coverage (ABN) form that is used for traditional Medicare beneficiaries. QuestionWhat are the advance beneficiary notice of non-coverage modifiers? Answer QuestionWhat is the description of each of the modifiers? Answer QuestionWhen would I use each of the modifiers? Answer QuestionDoes the Centers for Medicare and Medicaid have any resources regarding the ABN? Answer I hope you found this article informative and that you now have a better understanding of the modifiers associated with the ABN form. In addition, be

UnitedHealthcare (UHC) Individual Exchange Plan has announced they will begin requiring additional modifiers be appended to CPT codes on both the 1500-claim form and UB-04 claim form in order for outpatient therapy services to be reimbursed. Failure to append the new modifiers on each CPT code will result in those claim lines being rejected. The new modifiers that are required beginning with dates of service on and after September 1, 2021 are either Modifier 96 or Modifier 97. Modifier 96 is to be appended to the CPT code on the claim form to indicate that the service is Habilitative in

UnitedHealthcare (UHC) Commercial and UHC Oxford have updated their Coverage Determination Guideline for speech generating devices with an effective date of July 1, 2021. To access the updated policy for UHC Commercial, click. To access the updated policy for UHC Oxford, click In addition, UHC Community plan has developed a Coverage Determination Guideline for speech generating devices for the state of Mississippi with an effective date of August 1, 2021. To access this new guideline, click Thank you for being a Gold Member!

As some physical therapists, occupational therapists and speech-language pathologists continue to specialize in the services they provide, a question I am often asked is do insurance carriers, especially the Medicare program, allow a beneficiary to attend therapy (same discipline or different disciplines) at more than one location during the same time period and reimburse both locations for the services they provide? Let’s answer this question! The Medicare program I hope you found this article helpful. Thank you for being a Gold Member! All material posted on our website is intellectual property of Gawenda Seminars & Consulting, Inc. and can’t be

Many provides have a good understanding of the National Correct Coding Initiative (NCCI) edits utilized by the Centers for Medicare and Medicaid Services (CMS) as well as other commercial insurance carriers, including some workers compensation carriers. However, most providers of outpatient therapy services are either unaware or lack a solid understanding of CMS’ medically unlikely edits (MUEs). In this article, I will answer the following questions: What are medically unlikely edits (MUEs)? What outpatient therapy practice settings does CMS apply MUEs to? Are there different MUEs for a private practice (submit claims on a 1500-claim form) and a facility-based provider

I receive many questions regarding coverage of outpatient therapy services by the Medicare program when the Medicare beneficiary is also receiving home health services. In this article, I will answer 7 of the more frequently asked questions I receive. Question Does the Medicare program pay for outpatient therapy services at the same time the Medicare beneficiary is receiving home health services? Answer Question If a Medicare beneficiary is receiving physical therapy and/or occupational therapy under an open home health episode of care and also requires speech therapy, but the home health agency does not provide speech therapy, will the Medicare

More and more physical therapists (PTs), occupational therapists (OTs) and speech-language pathologists (SLPs) are establishing private practices that focus on seeing patients in their home for outpatient therapy services. The Centers for Medicare and Medicaid Services (CMS) does allow PTs, OTs, and SLPs to treat Medicare beneficiaries in their home as outpatients and pays for those services under the Medicare Physician Fee Schedule just as CMS would pay if the Medicare beneficiary went to a private practice or other outpatient therapy setting (except for a critical access hospital who is reimbursed on a cost-ratio basis). However, what is considered a

Recently, I have been receiving emails from my followers as well as seeing an increased discussion on social media platforms regarding the billing and payment of CPT code 97140 (manual therapy) on the same day the same provider also bills CPT code 29581 and/or 29584 (application of a multi-layer compression system). So what is the issue with payment of CPT code 97140 when performed on the same date of service that the provider also bills CPT code 29581 and/or 29584? According to I hope you enjoyed this article. Thank you for being a Gold Member!