The Advance Beneficiary Notice of Non-Coverage (ABN) is used when normally the service(s) or item(s) would be covered by the Medicare program, but under the circumstance, a provider does not think their Medicare Administrative Contractor will pay for a service(s) or item(s). A question I have been receiving lately is can a provider of outpatient therapy services use an ABN for Medicare Advantage (MA) plans to indicate to the MA plan that they (the provider) believe the MA will not pay for a service(s) or item(s)? The ABN is to be used

The Centers for Medicare and Medicaid Services has released the National Correct Coding Initiative (NCCI) Edits Version 24.1. NCCI Edits Version 24.1 is applicable for dates of service April 1, 2018 – June 30, 2018. There are 2 versions of NCCI Edits Version 24.1; one version is for private practice and the second version is for all other outpatient therapy settings that would include rehabilitation agencies, skilled nursing facilities, home health agencies, comprehensive outpatient rehabilitation facilities and hospital outpatient departments. There are 15 new edits in both Versions of 24.1. To access NCCI Edits Version 24.1, click HERE and then

A question I often receive is does the Medicare program pay for a Medicare beneficiary to receive outpatient therapy services while they are simultaneously receiving home health services under an open home health agency (HHA) plan of care? In this article, I will answer this question plus provide resources for the outpatient therapy provider to determine if the Medicare beneficiary is receiving home health services. The answer is

The Office of the Inspector General (OIG) has issued a report regarding the findings of a review they conducted on outpatient physical therapy services provided to Medicare beneficiaries between July 1 – December 31, 2013. For calendar year (CY) 2013, the Medicare Part B program paid approximately $1.8 billion for outpatient physical therapy services provided to beneficiaries. The OIG sampling frame consisted of 9,037,556 outpatient physical therapy service claims with a place of service code of 11 (signifying that the therapist provided the service in an office setting), totaling $635,771,872, of which we reviewed a stratified random sample of 300

I often receive the following questions regarding massage and manual therapy: What is the description of massage and manual therapy? Does the Medicare program pay for massage and manual therapy? What is the difference between massage and manual therapy? What is the difference in payment between massage and manual therapy? Do private insurance carriers pay for massage (CPT Code 97124) In this article, I will answer the above 5 questions. According to the American Medical Association (AMA), CPT 2018 Professional Edition, the descriptions for massage and manual therapy are as follows:

The Centers for Medicare and Medicaid Services has issued guidance to the Medicare Administrative Contractors (MACs) how to reprocess outpatient therapy claims that were previously denied before the passage of the Bipartisan Budget Act of 2018 or were denied after the passage of the Bipartisan Budget Act of 2018 even though the KX modifier was appended to services that had been delivered above $2010 in calendar year 2018. In addition, some MACs will have to reprocess therapy claims due to changes in the Work Geographic Price Cost Index (GPCI) floor. This means that some providers in some states will see

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, requires the Centers for Medicare and Medicaid Services (CMS) to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status. Beginning in April 2018, CMS will start mailing the new Medicare cards with the MBI to all people with Medicare in phases by geographic location.CMS plans to have a transition period where providers can use either the HICN or

First Coast Service Options, Medicare Administrative Contractor for the State of Florida as well as Puerto Rico and the U.S. Virgin Islands, has posted updated Targeted Probe and Educate (TPE) topics. To no surprise, the list includes inpatient rehabilitation facilities, skilled nursing facilities and outpatient therapy providers. Topic list below includes service specific TPE reviews as they pertain to therapy services in various settings: