I am often asked by providers of outpatient therapy services how to identify who the certifying physician/non-physician practitioner (NPP) or physicians/NPPs are on the claim form. The answer depends on whether you are a private practice submitting claims on the paper 1500 claim form or the electronic equivalent (i.e. 837P) or you are an institutional provider (i.e. skilled nursing facility, rehabilitation agency, CORF, or hospital outpatient department) submitting claims on the UB-04 electronic claim form (837I). In this article, I will provide the answers to the above including how to identify multiple physicians/NPPs on the claim form when one physician/NPP

Breaking News July 2, 2019: Anthem BC announces they will delay implementation of AIM until August 1, 2019. Here is the statement issued by Anthem:

Effective July 1, 2019, Anthem Blue Cross patients in several states will require preauthorization to receive outpatient physical, occupational and speech therapy services. This will be true not only for new patients beginning therapy on or after July 1, 2019, but also for current Anthem patients who are being seen now and will continue to be seen for therapy on or after July 1, 2019. The states where prior authorization will be required effective for dates of service on and after July 1, 2019 are:

For dates of service on and after July 1, 2019, the Centers for Medicare and Medicaid Services (CMS), as well as UnitedHealthcare (UHC), is changing which CPT code Modifier 59 must be appended to on the claim form in order for both the Column 1 and Column 2 CPT codes to be paid when provided on the same date of service. If you missed my webinar last week on NCCI edits and Modifier 59, click HERE to see the complete webinar description, objectives and to order the recorded version with handouts and Gawenda Seminars & Consulting NCCI edit reference sheet.

One of the most common questions I am asked via email and in-person during a seminar is “When does an order for therapy expire” or “How old can an order be before a patient starts therapy”? To answer this question, we must look in 3 places. The first is your  

Novitas Solutions, Inc, Medicare Administrative Contractor in the states of Arkansas, Colorado, Delaware, Louisiana, Maryland, Mississippi, New Jersey, Oklahoma and Pennsylvania as well as the District of Columbia, has released a revised local coverage determination (LCD) on Modifier Barium Swallow Studies. The LCD provides covered indications where instrumental assessment of swallowing may be helpful as well as the settings where the procedure will be reimbursed if medically necessary. To access the LCD, log into your account and click

A question I often receive is can a new graduate physical therapist or graduate physical therapist assistant treat Medicare patients while they are waiting to take their national examination and have their services supervised by a licensed physical therapist (PT) or physical therapist assistant (PTA) and billed to the Medicare program? Does the Centers for Medicare and Medicaid Services (CMS) answer this question and if yes, where is the answer? In this article, when I mention Medicare, I am referring to traditional Medicare and not Medicare Advantage plans. Yes, CMS does answer this question and the answer can be found

This article was originally published on May 20, 2019. Information has been updated as of June 3, 2019. Please read below for further details. Changes are coming to UnitedHealthcare and billing for outpatient therapy services. Failure to be aware of this change will cause your claims not to be paid beginning this summer. UHC has announced they will begin requiring the application of the therapy specific