Wisconsin Physician Services (WPS) has published the results of their recent Targeted Probe and Educate (TPE) audit. The TPE impacted Indiana and Michigan and CPT codes 97112 and 97530. For private practices, the results of the TPE audit for 97112 was a 15% error rate. For all other settings, the results of the TPE audit for 97530 was a 23% error rate. Most likely, the two main issues were: if you have a concern about the documentation, or lack thereof, occurring in your practice or organization, I would recommend the following 2 webinars:

A question I receive is must a provider issue a Notice of Medicare Non-Coverage (NOMNC) to Medicare beneficiaries when outpatient therapy is ending? The following settings are required to issue a NOMNC to a Medicare beneficiary when outpatient therapy is ending:

With the success of Artemis 2 and its orbit around the moon, I thought I would write an article on how the MOON impacts outpatient therapy. What is a Medicare Outpatient Observation Notice (MOON)? Who is required to provide a MOON to a Medicare beneficiary? In this article, I will answer the following questions:

If you have read one commercial insurer’s therapy policies, you have read one commercial insurer’s therapy policies. That is why I have created an extensive frequently asked questions (FAQs) page dedicated to Aetna and outpatient therapy. This Aetna FAQ page will provide you answers to some of the most common questions I receive regarding Aetna and outpatient therapy services. Questions answered include, but are not limited to: To read the answers to the above questions, click HERE.

Medicare’s 8-minute rule remains very confusing not only for therapists and assistants, but also for billers, practice managers, owners of private practices, and facility directors and administrators. That is why I have created an extensive frequently asked questions (FAQs) page dedicated to the 8-minute rule. This 8-minute rule FAQ page will provide you answers to some of the most common questions I receive regarding this topic. Questions answered include, but are not limited to: To read the answers to the above questions, click HERE.

The National Correct Coding Initiative (NCCI) Edits Version 32.1 are in effect for dates of service April 1, 2026– June 30, 2026. NCCI edits are used in all outpatient therapy settings for original Medicare and Medicaid beneficiaries. In addition, some Medicare Advantage plans, commercial insurers, and workers compensation programs also utilize the NCCI edits. Gawenda Seminars & Consulting has created a NCCI Edit therapy specific reference sheet for both Medicare and Medicaid. These reference sheets will inform providers when modifier 59 is required on a CPT code on the claim form. In addition, the reference sheet will inform providers what combination of

On March 20, 2026, the Centers for Medicare and Medicaid Services published a final rule implementing requirements of the Administrative Simplification subtitle of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This final rule establishes the first-ever Health Insurance Portability and Accountability Act (HIPAA)-adopted standards for health care claims attachments. The rule also establishes requirements for electronic signatures to ensure health care claims attachment transactions are secure, authenticated, and compliant with federal standards. To access the final rule Fact Sheet, click HERE. To access the final rule, click HERE. Compliance with the final rule regulations is May 26, 2028.

The Centers for Medicare and Medicaid Services (CMS) and commercial insurance carriers, such as Anthem BCBS and UnitedHealthcare, have increased their requests for medical records for dates of services to ensure not only proper CPT coding and billing, but that the services provided meet the definition of medical necessity and required the unique skills of a therapist, or an assistant under the supervision of a therapist, to provide. Unfortunately, providers are not submitting all of the required information and thus, are being denied even when the daily note does support the CPT codes and units billed. In this article, I