The Pathway to Payment and all the Bus Stops Along the Way
Bus Stop #1: Credentialing
The first stop along the Pathway to Payment is to ensure that your providers are credentialed and participating with multiple payors. Becoming a participating provider (“PAR”) with an insurance has its perks and patients generally are fearful of the terms “out of network” when they are selecting which providers they want to use.
The credentialing process may seem daunting at first - especially with the different forms, applications, provider numbers, and licensure documentation you have to provide, not to mention the processing time for your application. But, this is arguably the most important stop on a long road to getting paid.
If you have multiple locations within your practice, each one needs to be credentialed with each insurance you want to be a participating provider with. Each individual provider within your practice should also be credentialed with those insurances to avoid delays in completing documentation due to needing a co-signature.
Bus Stop #2: Insurance Verifications and Benefits
Once your practice becomes a participating provider with these insurances you can start accepting patients with those insurances. One of the perks of being PAR with these payors is that you can have access to online portals that are available. These portals are extremely convenient and give you access to a multitude of resources - benefit information being one of them.
Many of these insurances can be found on hub portals such as Availity, but other insurances have their own portals such as state Medicaid programs and Medicare. Setting up these portals is generally a simple process where you have to register your NPIs and TINs for each location, create a user login and password, then verify your information.
One of the resources on these portals lets you check benefit information for policyholders. This will help your practice as well as the patient have a better understanding of patient responsibility and cost-share amounts for the services you are providing. The most important items to confirm while checking benefits are:
Authorization requirements (be sure to confirm if this is handled by a third party vendor rather than the insurance)
Copays
Coinsurance
Deductible
Out of pocket expenses
Visit limits (this is not the same as authorized visits)
After you have verified the benefits and confirmed accumulations for each cost-share item, provide this information to the patient prior to him/her starting treatment. This is best done by completing a financial responsibility sheet or insurance benefits information sheet to include in the patient’s intake paperwork. The patient should attest to the benefits information and acknowledge that he/she is aware of the potential patient responsibility throughout the course of treatment.
This ensures there are no surprises to the patient or to your practice once the claims process. If the patient has a copay, you will be aware of that and can collect the copayment at each visit, rather than waiting to collect it once the claims process and your chances of collecting are significantly reduced once the patient leaves your clinic.
Bus Stop #3: Authorizations
Some insurance plans require authorization - and depending on the insurance this may be referred to as clinical submissions, precert, medical necessity review, etc. - so it’s important to understand each payor and the terminology they use when requiring an authorization. If this information is not on the portals then someone must call the insurance to confirm the authorization requirements. During a time where technology has consumed almost every aspect of society, a good old fashioned phone call to speak to a representative about the authorization is always worth making.
Online Portals / Requesting Authorizations
This information should be collected during the benefits check back at Bus Stop #2. The process for obtaining authorization should also be obtained during the benefits check. This is also a feature on some online portals where the benefits information is located, however, if the authorization is handled by a third party vendor, then you need to contact that vendor to have your processes in place for submitting these authorizations. These third party vendors often also have online portals to submit and check the status of authorizations.
Tracking System
There needs to be a diligent system in place to track and monitor your patients who require authorization. If the authorization is required before the eval, then your team needs to ensure the necessary steps are being taken to get the auth requested prior to eval date. There are several nuisances about authorizations that are imperative that you are aware of and you should always confirm which CPT codes require authorization.
Tracking and submitting authorizations will avoid losing reimbursement for services rendered due to missing authorizations. Your entire team should be involved in this process so they understand the “why” behind the importance of diligent tracking and requesting authorizations when they are needed. Once the authorization is approved and can be tracked in your billing software your team should be able to run reports and view patient charts to see when the authorization expires/the patient needs more visits.
Retroactive Authorizations
If an authorization is missed the next option is to attempt a retroactive request for authorization. Many insurances do not allow retroactive authorizations, but again, this information should be obtained during the initial benefits verification. If the retroactive authorization is denied, the final resort is appealing for medical necessity.
Bus Stop #4: Submitting Claims
This stop is one of the most satisfying stops along the Pathway to Payment. It combines all of your efforts from the previous stops and sends them off to the insurance for processing. This stop is also the intermission stop where we wait for the connecting bus to take us to the next stop.
Many payors have transitioned to electronic submissions of claims. Every billing software should have the option to physically print these claim forms and mail to the insurances as well as an option to set up EDI for electronic submissions for quicker turnaround times for claims processing.
The two key focuses at this stop are 1) ensure each payor is set up correctly and 2) be aware of timely filing deadlines.
When the payor settings are incorrect or do not coincide with the information the payor has on file for your location is when you run into denial issues which ultimately put you at a race against the clock to have claims resubmitted. Getting claims out the door is at its core the purpose of the revenue cycle, but getting claims out the door correctly the first time is what the focus should be on.
Common issues with claim submissions include submitting claims to the wrong physical address, having the wrong EDI set up for electronic claims, missing information on the claim forms, and missing timely filing deadlines. All of this information is easily attainable and should receive a high level of attention from the beginning. Once these payors are set up in the billing software you will likely not have to edit them again.
Take time to refine your process and ensure everything in your billing software is set up correctly before mass submitting claims. Once the claims are out the door - we wait.
Bus Stop #5: Accounts Receivable
At this point, we are about 30-45 days out from the first time a patient entered your practice for services. This stop is also very satisfying because you see the hard work from Stops #1-5 pay off - literally.
Overall, you should have a processed mapped out and strategy in place on how you will handle these sets of aged claims. The AR Team needs to be aware of nuisances across insurances as well as timely filing deadlines.
These items should be tracked and handled in an efficient and timely manner.
0-30 Days Aged
Aging reports for claims should be run in a timely manner starting with claims that are 0-30 days aged. Many of these claims will still be processing but it is important to keep track of them because 30 days quickly turns into 90 days if you are not conscientious of the aging process and running the aging reports.
30-60 Days Aged
Claims that have aged 30-60 days should be a primary focus since this is where you will catch any denials or rejections from either the clearinghouse (if claims were submitted electronically) or the insurance company for invalid/incorrect/missing information on the claim forms. This is a crucial bump in the road that can be remedied and the potential to collect on these claims is highly likely since this is usually still within most insurances’ timely filing limits.
60-90 Days Aged
This aging bucket is where you should be concerned with the reason for these claims aging out this far. Did the insurance pay and now you are waiting for the patient to pay? Did you miss a denial? What next steps need to be taken to resolve these claims?
90-120 Days Aged
This group of aged claims should sound the alarm for your AR Team. These claims either fell through the cracks of the previous aging buckets or you are waiting for payments from patients. At this point, all hands should be on deck to get claims reprocessed at the insurances - if timely filing limits allow this - or patients need to be called about their outstanding balances.
120+ Days Aged
Any claims outstanding at insurances at this stage should be addressed immediately to resolve the issues. If there is no other remedy for the claim, it will likely result in a write off.
Any patient balances that have aged this far should also be addressed immediately by making final calls to collect on the outstanding balances before they are sent to collections.
Bus Stop #6: Denials and Appeals
The final stop on the Pathway to Payment is addressing any denials that are discovered in the AR process at Stop #5. Common denials include missing authorizations, invalid member ID, missing provider information, and missing clinical documentation. Each of these can be easily avoided at their respective stops along the Pathway, which is why it is important to take your time at each stop to ensure everything is handled correctly before going to the next stop.
If the claims are returned for denials, some of the issues can be resolved by resubmitting the claims with corrected information and/or documentation.
Other claims may require additional work such as filing an appeal if they are denied for medical necessity or missing authorization. The appeals process for each insurance is different in that some require forms to be completed while others allow for a more informal request for appeal.
Either way, all insurances have timely filing deadlines for these appeals and they should be strictly abided by. This is your last chance to get paid on claims.
Paul Martin's Interview with Bryanne Johnson
Our CEO and Founder, Bryanne Johnson discusses the reimbursement challenges and opportunities as we move forward into 2021. Link provided below:
Things You Should Know, February 2021 Edition
Recently CMS published CCI edits that are effective retroactively to January 1, 2021. These edits significantly reduce the use of the 59, X, XE, XP, XS, and XU modifiers.
Historically, these modifiers have placed a significant burden on practices both clinically and administratively. These are the denials, adjustments, addendums and appeals that are worked day in and day out by our clinical and billing teams to obtain reimbursement for services furnished separately and distinctly.
We are excited to spread the news that Cigna, Aetna and now Humana have followed the course of CMS and have also eliminated the use of the modifiers in coding pairs that will be significant to our industry.
Each insurance company is taking a different route in processing the claims retroactively to January 1, 2021. Read more from the APTA here.
Have questions about your billing or coding? Questions about how to retroactively bill these claims? Let us know- we're here to help!
Happy Birthday, Mr. Lincoln!
As Abraham Lincoln once said, "give me 6 hours to chop down a tree and I'll spend the first four sharpening the axe."
At LRS, we pride ourselves on efficiency and process improvement. Our company is named after Abraham Lincoln - we focus on ways to make your practice more efficient and in turn, collect every penny of what you are owed.
As we venture into 2021, we have found the three points below as being a solid foundation for billing, coding and reimbursement. Struggling in one of these areas? Let's chat!
Coding Best Practices
Moving from basic to advanced activities - purpose, progression and compliance.
CMS v. AMA 8-Minute Rule
How each work and what they mean for you, your billing and your reimbursement.
59 Modifier Denials and Adjustments
Payers we see this with, adjustments v. denials, and how to approach these.
Stop Jumping Through Hoops in 2021!
Do you find yourself constantly jumping through hoops when it comes to credentialing?
Insurance companies have many hurdles in place to delay payment and oftentimes, credentialing providers can be one of the most exhausting - especially when you don’t want to focus on paperwork but instead on patient care and the customer service experience within your practice!
Here are some common hoops we see in credentialing and ways they can be combated:
Insurance panels closed:
It can take up to six months to hear back from an insurance panel once you have submitted an application! And after all that waiting, the insurance companies can come back saying that they are not open to taking new providers. This is incredibly frustrating but the best thing you can do in this time is be persistent. Continue to apply every 3-6 months. Follow-up with statistics and outcome measures as to why your practice should be selected to enter into the plan.
Extended wait times for processing especially due to COVID-19:
While waiting is the name of the game when it comes to credentialing, since COVID-19, we have seen even longer processing times due to the transition to remote workplace and the payors focus on putting in place waivers for Covid-19 emergency. We recommend continuing to submit credentialing in a timely manner but anticipate prolonged approvals times and plan for co-signs in the interim. Again - this is where persistence is key! Continue to follow-up regularly with the payors to ensure your applications are processing.
Lack of communication with your billing team causing denials:
Your billing and credentialing departments should have a solid process in place for communicating credentialing status’ and how that directly affects the submission of claims. It’s essential that your credentialing department shares all crucial information, including: pending, approved, and terminated credentialing status’; claims that need to be held and when those claims are okay to be submitted; and contract intricacies to ensure that the EMR and claims reflect the contract details. If not, you will see denials that are often not appealable.
We know that credentialing and re-credentialing and the hoops they have can cause you and your practice headaches and cause delays for cash flow. If you are interested in having LRS handle your credentialing, contact us to learn more!
Busting a Move into 2021
Busting a Move into 2021
We have been through so many things this year. COVID-19 uprooting our ways of living and working. NCCI edit reversals and what has felt like endless denials because of these changes. And to cap it off - the CMS Final Rule solidifying Medicare payment cuts.
But now we are less than 2 weeks away from 2021. It is time to focus on the future and what you can control. You can finally put back on your dancing shoes and get your practice ready to move and groove again in the New Year!
Here are a few things you should be doing to ensure you will be rocking into 2021:
1) Analyze your collections and your AR.
Do you know what your revenue per visit is? How has it trended in 2020? How has your payor mix shifted through COVID-19? How much of your AR is outstanding at 90+ days? We know the Medicare payment cuts are coming but that is exactly why you should be ensuring your AR is as clean as possible. Collect on every penny you are owed. It is your best safeguard against the payment cuts.
2) Appeal. Appeal. Appeal.
While it seems the NCCI edits may be reversed, AGAIN, in the coming year - you have likely taken a huge hit since they were reinstated in October. Have you analyzed your revenue per code for popular NCCI edit users like Humana and BCBS? Take a look at common bundling denial codes such as 97530 and 97140. Have those been adjusted off or are they in the appeals process? Just like collecting on your AR, appealing these codes are an essential way to make up the difference for the looming payment cuts.
3) Clean up your administrative processes.
Did you receive credentialing denials in 2020? These are completely avoidable. What is your referral conversion rate? How many denials did you receive for no authorization this year? Due to the upcoming payment cuts and continued COVID-19 surges, you cannot afford to be receiving denials for these preventable issues and you also need to be focused on getting as many patients on the schedule as possible in the New Year.
Are you worried about your answers to these questions and that you may be late to the 2021 dance party because of it? LRS can help! We can do a free strategic analysis and reconciliation to see where you may be missing out on cash in the bank. Contact us today to learn more!
Boots On The Groud Webinar
Join the LRS' leadership team for an interactive webinar on Wednesday, December 2nd at 12:00pm EST that will highlight trends in denials, authorization for services, credentialing and contracting, and other billing issues that you should be aware of as you prepare your strategic plan for 2021.
Thing You Should Know This Week 11.19.2020
2021 Medicare Deductibles and Premiums Announced
CMS announced the 2021 Medicare Part A and Part B Deductibles and Premiums:
The standard monthly premium for Medicare Part B enrollees will be $148.50 for 2021, an increase of $3.90 from $144.60 in 2020.
The annual deductible for all Medicare Part B beneficiaries is $203 in 2021, an increase of $5 from the annual deductible of $198 in 2020.
The Medicare Part A inpatient hospital deductible that beneficiaries will pay when admitted to the hospital will be $1,484 in 2021, an increase of $76 from $1,408 in 2020. The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period.
99072 Use
As we shared before, the AMA released the new CPT code 99072 to be used for "Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency as defined by law, due to respiratory-transmitted infectious disease."
Additional means above and beyond what you would normally perform on a typical visit.
Tricare and Low Back Diagnosis Coverage
TRICARE is now offering a program that waives cost-sharing for up to three physical therapy visits for people with low back pain. This program will be available between Jan. 1, 2021, through Dec. 31, 2023, for those that have TRICARE insurance and live in one of these 10 states: Arizona, California, Colorado, Florida, Georgia, Kentucky, North Carolina, Ohio, Tennessee, and Virginia. Learn more about the requirements at ChoosePT by the APTA.
Save the Date: Next LRS Webinar
Join us on December 2nd at 12pm ET for our next webinar: LRS' Boots on the Ground - What We Are Seeing Heading Into 2021. The LRS leadership team will highlight trends in denials, authorization for services, credentialing and contracting, and other billing issues you should be aware of as you prepare your budgets and plan for 2021.
Essential Billing Benchmarks for 2021
Here are three billing benchmarks that LRS recommends being aware of at all times:
Denial/First Pass Payment Rates
How many denials are you receiving and how many claims are paid on the first submission? Many factors go into these metrics including accuracy of patient intake and registration information, correctness of insurance verification and authorization information, and how claims are being submitted per payor guidelines. A very efficient practice will have a denial rate under 5% and a first pass claim rate higher than 95%.
Percentage of Receivables over 120 Days
How quickly are you collecting the money you are owed? You should be aiming for less than 10% in the 120+ aging bucket. There are always going to be issues with specific claims but a healthy practice has about 75% of their AR in under 60-days outstanding.
Payer Mix/Expected Revenue per Payer per Visit
Who are your top 5-10 payers? What are they paying you per visit? Your overall cashflow is very dependent on your payor mix and what each payor is paying you per visit or per unit on average. This is an important metric every practice should monitor closely. Maybe it is time to try to renegotiate contracts, to consider going out-of-network with some insurances or maybe it’s time to use your marketing dollars more strategically.
These are only a few of the metrics you should be reviewing on a monthly basis. Do you see room for improvement in your practice? Contact us today at hello@lincolnrs.com to see how we can help you improve these essential benchmarks.
Fighting the NCCI Edit Denial Wave
As of October 1st, CMS has reinstated many of the procedure-to-procedure edits, which are more commonly known as the National Correct Coding Initiative Edits (NCCI edits). This rule was actually deleted earlier this year, however, it is effective again for PT, OT and speech outpatient therapy services. We are seeing denials for NCCI edit-related issues come in at a rapid pace from many insurance companies especially when it comes to the use of 97530. Your practice is likely facing this same issue.
What can you do to minimize these denials, ensure you are catching them on EOBs, and appealing them successfully?
1) Make sure your EMR is set up properly: Your EMR can be your best defense when it comes to adding the 59 modifier to appropriate codes that are separate and distinct. Check within your company, clinic, and carrier settings to ensure they are set up with the proper modifier functions.
2) Make sure your documentation is correct: If you are performing truly separate and distinct services, a therapist's documentation needs to reflect this. Even with the 59 modifier attached to the codes, insurance companies are still denying or requiring additional documentation. At LRS, we provide strategic coding audits to evaluate a therapist's documentation to ensure that they are meeting the standards that insurance companies require regarding reimbursement as well as compliance and regulatory requirements.
3) Make sure you are analyzing every single EOB: More times than not, insurance companies adjust bundled codes and do not deny them. If your billing team is not looking strategically at EOBs, they are likely allowing this code to be adjusted off instead of marking it as denied. This can be causing your practice a significant amount of money.
4) Make sure your appeals process is up to speed: Set up a fluid and traceable communication process between your billing department and your therapists. Communicating in real time will allow your billing department to be agile and will lead to comprehensive reimbursement.
5) Make sure you are regularly checking reimbursement rates at the code level: This will help you flag any potential issues and investigate lags before they are problems.
Do you think you are missing the payments earned for the care that you deliver? Could a quick spot audit help? Could your appeals process use some standardization? Contact LRS today to see how we may be able to help you improve!
No Surprise Patient Balances: Why Verifications Matter!
Insurance verification and authorizations play an essential role in avoiding denials and patient ineligibility for services. They are also a key component in your customer service.
While it is the responsibility of a patient to know their benefits, we are all aware patients often do not even know what a deductible is - let alone how much they have remaining on it. If you don't present this information at the time of service, you could be dealing with an angry patient when they receive their bill for treatment down the line.
What Does the Insurance Verification and Authorization Process Entail?
There are several things that should be obtained when an insurance verification is completed. These include: payable benefits, co-pay amounts, co-insurance amounts, deductible amounts, effective date of plan, additional coverage details, whether authorization (or prior authorization) is required, confirmation of claims address, the patient's yearly maximum, etc.
While some insurances allow you to check benefits online and they can be completed fairly quickly, other insurances require up to an hour (!!) spent on the phone to obtain benefits. This can leave your front desk or office manager on the phone when they could (and should!) be interacting with the patients in your office.
By outsourcing your insurance verifications and authorizations you can:
Speed up approval process
Simplify your workflow
Improve payment and collections
Improve staff productivity
Improve customer service
...among many others!
At LRS, we have developed a standardized insurance verification and authorization process. We would love to tell you more about it. Let us help you avoid costly denials and angry patients through simplifying your processes!
Things You Should Know This Week 10.19.2020
We are grateful for the incredible care
you provide to your patients across the country!
Grace Period Extended for Medicare Accelerated and Advance Payments for COVID-19 Revenue Loss
In March 2020, CMS accelerated Medicare payments to hospitals and advanced payments to physicians and other providers to minimize the effects of revenue shortfalls. Providers that received the advanced and accelerated payments were scheduled to begin repayment of those loans in August 2020, but CMS delayed the start of repayment at that time. In the recent appropriations bill that was signed into law, Congress gave hospitals and other providers that received Medicare accelerated and advance payments one year from when the first loan payment was made to begin making repayments – delaying the start of the repayment period to spring of 2021. Learn more at CMS.
Expansion of Telehealth PHE Codes
CMS recently expanded the list of telehealth services that are available for reimbursement during the COVID-19 pandemic. This list includes nearly 100 CPT codes that are now reimbursable when following the appropriate CMS telehealth guidelines.
News Articles You May Have Missed
NY Times: How Physical Therapy Has Benefits for Back Pain
Chicago Sun Times: Physical therapy can be a key factor in recovery following breast cancer
Don't Be Spooked By 97530!
We understand why therapists are hesitant to bill 97530 - you may be concerned about denials or zero dollar payments.
However, we're here to tell you, don't be spooked by 97530!
There are several questions you should ask yourself when choosing a CPT code. These should all be looked at through the lens of intent of your treatment, progression shown for your patient and as always, compliance and regulatory standards.
By billing the correct contracted codes within the above guidelines, you may also increase your revenue per visit at the same time.
We are currently offering a complimentary chart audits to review your purpose, progression and compliance while also ensuring you are providing correct coding to maximize your reimbursement. Sign Up Here!
Things You Should Know This Week
Additional Stimulus Funds Available
HHS announced $20 billion in new funding for providers on the frontlines of the COVID-19 pandemic. HHS stated that providers who received Provider Relief Fund payments can apply for additional funding. Providers can begin applying for funds TODAY and the application period lasts through November 6th.
Learn more from HHS' full press release.
NCCI Edits Reminder
CMS has reinstated many of the procedure-to-procedure edits, which are more commonly known as the National Correct Coding Initiative Edits (NCCI edits). This rule was actually deleted earlier this year, however, it is effective again NOW for PT, OT and speech outpatient therapy services.
Some popular CPT codes that it impacts are:
Therapeutic activities
Aquatic therapy
Biofeedback codes
Evaluation codes
Manual therapy
The full list of CPT codes is available at CMS.
UHC Cost-Sharing Update
UnitedHealthcare is expanding cost share waivers for their Medicare Advantage and Individual and Group Market health plans for COVID-19 Treatment:
Individual and Group Market health plans: Cost share waivers (copay, coinsurance and deductible) for in-network COVID-19 treatment are extended through Dec. 31, 2020. Out-of-network cost share waivers will end Oct. 22, 2020. Implementation for self-funded customers may vary.
Medicare Advantage: Cost share waivers (copay, coinsurance and deductible) for COVID-19 treatment are extended through Dec. 31, 2020. This applies to in-network and covered out-of-network COVID-19 treatment.
For more details on telehealth billing guidance and provider type eligibility, visit UHC.
Deadline to Submit Comments to CMS on Payment Cuts
The deadline for comments is TODAY to fight the proposed 9% cut in payment for physical therapy services that is scheduled to begin on Jan. 1.
It only takes 60 seconds to submit comments so we encourage you to do so through APTA's link.
Building Success With Today's Coding Changes
Building a strong foundation for your PT practice has never been more important. From your clinicians, to your front office, to your billing team - every piece must work in tandem to deliver each visit successfully. One missing link and everyone's building block contribution to your practice will get lost.
One major piece of this is coding. You therapists need to be billing the correct codes for the services they are delivering and your billing team has to know which modifiers are important to be attached to those codes and how to get them paid.
If you don't have the right builders in place, things are about to get a lot more challenging for your practice. The recent and upcoming changes will have a major impact to your bottom line to the tune of up to $30/visit.
CMS has reinstated many of the procedure-to-procedure edits, which are more commonly known as the National Correct Coding Initiative Edits (NCCI edits).
This rule was actually deleted earlier this year, however, it will now be in effect TODAY - October 1st for PT, OT and speech outpatient therapy services.
Some popular CPT codes that it impacts are:
Therapeutic activities
Aquatic therapy
Biofeedback codes
Evaluation codes
Manual therapy
Just to name a few
Do you think it is time to get an inspection of your "building" to make sure your coding and billing practices are exceeding standards? Contact us, we would love to help!
We are offering a complimentary coding and billing assessment - click here to set one up for your practice.
Falling Into Increased Revenue
On September 21st, Lincoln Reimbursement Solutions CEO, Bryanne Johnson, and President, Danielle Pantalone, held an interactive webinar highlighting what is new in the news, what it means for you, and how you can spend this next season "falling" into increased revenue.
Topics Covered Include:
The CMS Proposed 2021 Physician Fee Schedule
8-9% reduction in payments
How to advocate against these cuts
Outpatient Therapy Modernization and Stabilization Act (HR 7154)
Reprieve from Medicare cuts
Updates to telehealth
Small boots in fee schedule
PPP and Medicare Accelerated payments:
Tips for what you should be doing today to prepare for repayment/forgiveness
Updates to telehealth:
Permanent policy solution proposed
Cost-sharing and how to handle with patients
Updates to the NCCI edits:
Reinstatement of code pair prohibitions effective 10/1
How this impacts commercial payers
You can watch the webinar at this link.
Still have more questions about these topics or something else? Contact us at hello@lincolnrs.com today!
New CPT Code to Cover COVID-19 Related Costs
On September 8th, the American Medical Association released a new CPT code (99072) to report the cost of additional personal protective equipment (PPE), cleaning supplies, and clinician / clinical staff time needed to safely provide in-person services during the public health emergency due to COVID-19.
99072 was created to capture the cost of supplies and activities required to reduce the spread of COVID-19. It can only be used 1x per encounter per day and in non-facility settings.
CMS, state Medicaid plans, and commercial payers have not yet announced whether they will cover this code and if so, what the fee schedule will be. We recommend having your billing team call insurance companies to obtain this information.
Things You Should Know This Week
TAKE ACTION: Planned Medicare Cuts 2021
As we mentioned in a previous email, the current CMS proposed rule has a 9% reduction for physical therapy and occupational therapy payments and an 8% proposed cut to speech therapy payments.
Over the last six months, you have cared for your patients at unprecedented levels while also fighting to keep your businesses intact. Now is absolutely not the time for CMS to cut reimbursement levels especially as we are entering another phase of the pandemic.
It is up to us to be as vocal as possible and tell our Members of Congress why this rule shouldn't take effect!
You don't need to be an APTA member to use this link to send a message to your Congressperson. It will take you less than 5 minutes but can have a huge impact on your bottom line come January 2021.
All comments are due by October 5th. Please encourage your colleagues, friends and family to weigh in on this issue as well.
UPDATES: NCCI Edit
In a reversal of course, CMS has announced that effective October 1, 2020, it will reinstate the previously deleted coding edits for code pairs including:
97530 with 97116
97530 with 97164
97161 with 97140
97162 with 97140
97163 with 97140
99281-99285 with 97161-97168
97110 with 97164
97112 with 97164
97113 with 97164
97116 with 97164
97140 with 97164
97150 with 97110
97150 with 97112
97150 with 97116
97150 with 97164
This is extremely unfortunate given CMS had just agreed to remove the edits in April. The full list of edits can be found on CMS NCCI Edits page.
When is 97164 Appropriate to Bill?
Therapists often get confused between when they should bill a progress note and when they should bill a re-evaluation. However, there are extremely strict guidelines when it comes to using each code.
Re-evaluations are not routine and shouldn’t be billed as such. Progress notes are routine and are completed at every 10th visit or every 30 days (whichever comes first).
According to Medicare, “Routine re-evaluations of expected progression in accordance with the plan of care, either during the episode of care or upon discharge, are not considered to be medically necessary separately billable services.”
When medical necessity is supported, a re-evaluation (97164) is appropriate for:
A patient does not respond as anticipated to the treatment outlined in the current plan of care, and a change to the plan is necessary.
A patient undergoes surgery mid-plan of care.
A former patient returns to therapy after discharge with complaints similar to those you treated previously.
A current patient develops a newly diagnosed, related condition.
A current patient develops a newly diagnosed, unrelated condition.
A patient undergoing therapy treatment demonstrates an unexpected and significant change in status.
It is important to note that 97164 can be billed and bundled with other 97xxx codes with the addition of the 59 modifier to indicate the service is separate and distinct.
Still confused or have additional questions about the use of 97164? Contact LRS at hello@lincolnrs.com and we can help!