On July 15, 2019, the Centers for Medicare & Medicaid Services (CMS) released a proposal to cover acupuncture for Medicare patients with chronic low back pain (CLBP) who are enrolled participants either in clinical trials sponsored by the National Institutes of Health (NIH) or in CMS-approved studies. To read the proposed decision memo, click HERE. To submit comments on the proposed decision memo, click HERE.

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  

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

There are many modifiers providers of therapy services are use to adding to CPT codes on the claim forms. Common modifiers include the KX modifier, 59-modifier and therapy specific modifiers of GN, GO and GP. But do you know the following modifiers and when to use them: GA, GX, GY and GZ? In this article, I will discuss when to use these modifiers on a CPT code on the claim form for therapy services. In addition, if you have additional questions on when to issue an advance beneficiary notice of non-coverage (ABN) form to a Medicare beneficiary, check out my

Lately, I have been receiving questions regarding what must a therapist or an assistant document in regards to time for patients receiving outpatient therapy services under Medicare Part B. Does the Medicare program require time in and time out? Does the Medicare program require we document the minutes spent on each individual CPT code. In this article, I will answer what the Medicare program does and does not require in terms of documentation of time for each therapy visit as well as Medicare Advantage plans, Medicaid, private/commercial insurance carriers and workers compensation carriers. For outpatient therapy services provided under Medicare

The Centers for Medicare and Medicaid Services (CMS) has released a new booklet where they describe common outpatient rehabilitation therapy services Comprehensive Error Rate Testing (CERT) Program errors, how the CMS calculates improper payment rates, the necessary documentation to support billed Medicare claims, and managing potential overpayments. Some of the more common CERT errors include:  

Last week, the Office of the Inspector General (OIG) published 3 enforcement actions involving physical therapy. I will provide a brief summary of the 3 enforcement actions and a link to each action. In the first enforcement action, physical therapist Hatem Behiry was found guilty of participating in a $30 million scheme to defraud Medicare and the New York State Medicaid Program. Per the OIG report, Hatem Behiry “pretended to provide physical therapy to many of those same patients, most of whom were receiving cash kickbacks for coming to the Clinics”. In addition, BEHIRY “also prepared and oversaw the preparation