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Switching to Medicare During an Episode of Care

I am often asked how to report Functional Limitation G-codes and PQRS codes on patient’s who began therapy with a commercial insurance (i.e. BCBS, Aetna, Cigna, UnitedHealthcare, etc.) as their primary insurance and during the therapy episode of care, Medicare becomes the primary payer. In this article, I will answer this question. In addition, check out our FAQs on Functional Limitation Reporting and 2016 PQRS.

Regarding Functional Limitation Reporting, on the first visit that the Medicare program is the primary payer, the provider would need to

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CPT Code 97750: When Do I Use This Code

CPT code 97750 is a code that many providers of therapy services do not understand when to use this code, when not to use this code and what interventions are included under this code. I often receive questions regarding CPT code 97750 such as:

  1. When can I bill CPT code 97750?
  2. Can we use CPT code 97750 in place of a reevaluation if an insurance carrier does not pay for a reevaluation?
  3. Can we use this code for the time it takes us to take range of motion measurements and perform manual muscle testing?
  4. Can we bill this CPT code for the time a patient completes a questionnaire and we review it with the patient?
  5. How often can we bill CPT code 97750?
  6. Can we bill CPT code 97750 for writing a Progress Report?
  7. Can we bill CPT code 97750 every 10th visit on Medicare patient’s when completing functional limitation reporting?
  8. What time counts towards “the each 15 minutes” when determining how many units to bill?

The description of CPT code 97750 is “Physical performance test or measurement (eg, musculoskeletal, functional capacity), with written report, each 15 minutes”. 

Lets now answer the questions from above.

When can I bill CPT code 97750?

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Reprocessing Claims for Audiology Services

Effective for dates of service on and after January 1, 2016, new HCPCS codes 92537 and 92538 for caloric testing replaced code 92543. These CY 2016 code changes were inadvertently left off of the Audiology Code List until March 31. As a result, some claims for audiologists’ services for codes 92537 and 92538 were unintentionally denied. Medicare Administrative Contractors will automatically reprocess these claims.

Medical Review of Skilled Nursing Facility Prospective Payment System Bills

The Centers for Medicare and Medicaid Services (CMS) has updated the instructions for the medical review of skilled nursing facility (SNF) Prospective Payment System (PPS) bills. The updated instructions include the following:

  • Skilled nursing facility qualifying inpatient stay
  • Types of SNF PPS reviews
  • Bill review requirements
  • Bill review process including obtaining records and making a coverage dertermination

To access the updated instructions, please click

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