The Hunt for Red Receivables in October: Live Billing Q&A FAQ

Our live billing Q&A webinar is always a fun time — particularly when you get to celebrate the canon of submarine cinema while providing education for rehab therapists. Our radar pinged on plenty of unanswered questions from our billing Q&A, so we enlisted our Compliance Chief of the Boat, John Wallace, to help viewers (and readers) navigate billing and coding challenges. 

WebPT/Keet/Therabill

Are there any more companies that will pay the Keet RTM codes (98975,97977,98980,98981)?

Medicare definitely pays for RTM. With commercial payers, you will need to check if it is a covered service.

I have a capitated contract that pays $300 per case, paid once, and could cover up to 12 visits.  What is the easiest way to log that in Therabill? 

You could enter the payer as an Agency and bill with an "agency statement"  that would include all dates of service and charges.  Once payment was received, you would post the payment and write off any amount above $300. You can read this Therabill knowledge base article on agency billing for more information.  

Is there a report that we can run to see what we are actually getting reimbursed by payer per CPT code or visit? Instead of the fee schedule?

 WebPT Billing and Insight do have reports on payment per visit by the payer; in Therabill, you can run an Insurance Payments by Code report.

Payer Policy Updates

Will Medicare Advantage plans still pay as OON?  What about their secondaries?

As this article from APTA notes, PTs will be paid at least at the Medicare rate for services provided to MA patients — although perhaps not as much as in-network providers.  We should also note that MA payers would never be secondary.

Although the list from UHC states Optumcare is not included, we are receiving claim denials saying auth is required as of September 1st. Is this a trend you've noticed? 

At the moment, this isn’t something that we have noticed.

Is Wyoming Anthem included in the cap? 

The Anthem announcement we discussed only involves Connecticut.

Is WebPT aware of denials from Blue Cross Blue Shield (BCBS) when outpatient therapy providers do NOT include start/stop times in their documentation? If yes, which type(s) of plans (Commercial, Medicare Advantage, etc)?  

Yes. this is a published policy on the Anthem website.

If you are OON with UHC, how do you charge the patient? Do they pay the full CPT Code amounts at the time of service?

As we mention in this blog, billing for services when you’re OON depends on whether you’re accepting assignment with a payer or not. If you accept assignment, you can either collect a fee from the patient upfront and then bill the payer for the remaining amount, or bill the payer and then collect the remaining balance from the patient later. If you’re not accepting assignment, you can either bill the payer on behalf of the patient or create a superbill for the patient so that they can seek reimbursement later from their insurance; either way, you would collect the full fee from the patient up front. 

If we’re out-of-network and not accepting assignment, do we have to follow out-of-network rates?  If we’re billing UHC Advantage, do we have to follow the Medicare fee schedule? 

No, but you cannot charge more than the Medicare Limiting Charge to Medicare Advantage patients.

Can you accept the assignment for some plans and not for other plans of the same payer? 

Yes, this can be done patient by patient.

Will Anthem / BCBS require Prior Auth on November 1?

You can visit Anthem’s Prior-Authorization and Pre-Authorization page and select your state to see what sort or prior authorization policies are in place in your state.  

Some UHC Indiana members require auth and some do not. Will that change? 

The UHC announcement only affects MA plans.

If we choose to become out-of-network with UHC, does that include their Dual Complete plan, too? 

If your contract with UHC covers that and that plan has OON coverage as a benefit, then yes. 

Where can I find updates for BCBS?

You can visit https://www.anthem.com/provider/news/ and select your state for the latest updates on BCBS/Anthem policies in your state.  

Medicare/Medicaid

Do Medicare patients need to fill out a Medicare Secondary Payer (MSP) form with their intake?

As this CMS resource on secondary payers states, Part B providers should:

• Follow proper claim rules to collect MSP information, such as group health coverage through employment or non-group health coverage resulting from an injury or illness;
• Check with the beneficiary during their visit to see if they’re taking legal action in conjunction with the services performed; and
• Submit an Explanation of Benefits (EOB) form with all appropriate MSP information to the designated carrier. If submitting an electronic claim, provide the necessary fields, loops, and segments needed to process an MSP claim.

When you say PTs should be billing under their own NPI,  that's not true for hospital settings, correct? 

That is correct.

Is the ABN form completed yearly? 

You should not have Medicare patients sign an ABN routinely. It should be signed only when it is required. As CMS notes on this ABN tutorial, an ABN remains effective so long as there are no changes to: 

• Care from what’s described on the original ABN
• The individual’s health status that would necessitate changes in the subsequent treatment for the non-covered condition
• The Medicare coverage guidelines for the items or services in question

Can I make a Medicare patient sign an ABN if the patient has exceeded their Medicare cap?

As we noted in this blog on The Ins and Outs of ABNs,

“Effective January 3, 2013, providers must issue a valid ABN to collect out-of-pocket payment from Medicare beneficiaries for services above the therapy threshold that Medicare deems not reasonable and necessary. It is imperative to understand that therapists should not issue an ABN for every beneficiary who exceeds the therapy threshold; rather, they should only do so when they believe the services in question do not meet Medicare’s definition of “reasonable or necessary.” 

What is the benefit of using an ABN?

An ABN allows you to provide and bill for services to Medicare patients that are likely to be denied under Medicare. The ABN makes clear to the patient that the financial responsibility for any denied services will fall on them.  

For that ABN option, wouldn't it be easier to just stop billing Medicare and have the patient pay out of pocket - no insurance rates? 

Therapy service providers cannot opt-out of Medicare and simply charge the patient cash. You must file claims with Medicare.

How can you find your error rate from Medicare? 

To find out your CERT error rate, you can access your information through the CERT C3HUB Provider website, which is managed by the Centers for Medicare & Medicaid Services (CMS).  That website allows you to check the status of your claims under review and view your CERT review results; you can also contact the CERT Documentation Center directly to inquire about your specific error rate

Does this group/single NPI issue only apply to Medicare? 

Each payer has their own EDI requirements. This information is available in the Payer Provider Manual.

For Medicare, what do you recommend when a clinic has to use traveling therapists for a short time? Is there anyone to avoid TPE since those therapists are not added under the facility tax ID? 

All therapists need to execute an 855R form to reassign payment to the practice. There are no Locum Tenens options for therapy services providers.

Are Medicare replacement policies paying on the re-re-eval code 97164? 

Yes, they are.  

Does using the 59 modifier for codes such as therapeutic activity & neuromuscular re-ed on a regular basis bring up red flags for Medicare? In this instance, the notes would justify the use of these codes. 

97530 and 97112 are not a current edit pair for NCCI. Routine use of the 59 modifier to Medicare for code pairs that are not NCCI edits can be flagged as aberrant billing.

Can we precollect the Medicare annual deductible?

According to the Medicare Claims Processing Manual, Chapter 2, section 10.4,  “When Prepayment May Be Requested”

“The provider may collect deductible or coinsurance amounts only where it appears that

the patient will owe deductible or coinsurance amounts and where it is routine and

customary policy to request similar prepayment from non-Medicare patients with similar

benefits that leave patients responsible for a part of the cost of their hospital services.”

The manual goes on to state that, 

“Except in rare cases where prepayment may be required, any request for payment must be made as a request and without undue pressure. The beneficiary (and the beneficiary’s family) must not be given cause to fear that admission or treatment will be denied for failure to make the advance payment.”

Can you charge the patient for canceled and no-show visits? Medicare and Medicaid?

Again, we turn to the Medicare Claims Processing Manual, Chapter 1 under Charges for Missed Appointments, where CMS says:

“CMS's policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge non-Medicare patients for missed appointments.”

The policy also states the providers must charge the same amount for cancellations and on-shows to all patients, both Medicare and non-Medicare. 

On Home Health denials…Is there really no way we can bill the patient for any amount recouped by Medicare because the patient failed to inform us that they are in Home Health? 

No, there is not. A patient cannot be covered under Part A and Part B simultaneously.

Do Medicare Advantage plans need a signed POC within 90 days?

As we discuss in this blog post, Medicare Advantage plans may or may not adhere to Medicare’s standards on a number of crucial points, including certification requirements. It would behoove you to check with specific payers on what their requirements are.   

If you are a cash-based business and not enrolled in Medicare, can you bill a patient for services if they sign a detailed payment agreement stating they know we are not enrolled in Medicare and that they cannot obtain reimbursement from Medicare for the services rendered?

The answer depends upon the services provided. As we cover in this blog post, you cannot provide medically necessary, covered services to Medicare patients and accept cash payment; you must bill Medicare for those services. You can accept cash payment from Medicare patients only for services that are excluded from Medicare coverage.  

We have a Medicare patient who has a referral for PT from a naturopathic doctor who is not a Medicare-qualified referring physician. Do we need to have a signed ABN?  Should we add a GA modifier? The patient’s secondary says they will pay if Medicare denies the claim. 

Use the GX modifier because this service is statutorily non-covered. You’d receive a denial from Medicare, and you can use that with the secondary.

What if the secondary is Medicare and the primary is commercial? They usually don't pick up patient responsibility in my experience.

The secondary should pay if the benefit paid by the secondary exceeds that paid by Medicare. They would cover the unpaid part of the allowable Medicare charge.

Are you required to bill a patient’s secondary insurance? Can you bill the primary and give them the information for them to bill their own secondary? 

If you are not a provider for their secondary insurance, you do not have to bill.

Can you explain how Medicaid crossover works and how documentation affects payment? 

Medicaid will pay if they pay more than is paid by Medicare; however, in most states, this is not the case. In these cases, you would follow Medicare’s documentation requirements.

Coding

We are not getting 97163 and 97110 paid together despite CCI edits saying they are payable with the 59 modifier.  Do you have any insight on how to get both codes paid when billed together? 

This is not a current NCCI edit, so billing these codes together should not be a problem with Medicare. If you have a commercial payer denying this pair, try applying the 59 modifier and be sure your documentation reflects that the services were rendered at separate and distinct times in the treatment.

What do you recommend for discharge summaries of observation patients in the acute care setting?  It probably goes without saying, but unanticipated discharges of patients in the acute care setting are more norm than the exception. 

All the therapist can document is what they know and observed while the patient was in Observation. Clinical insight and reasoning is part of any service, so they should document what they know and see when they are at the time of treatment. The Summary reflects those observations and clinical decisions and observations. A special or specific code is not required to capture that info.

I typically adjust codes after one or two progress notes;  is this needed?  I.E. for a post-op LE patient, for the top ICD-10 code I will start with Abnormalities of gait, and when that is improved, I will then have a new top code, like pain or stiffness. What about non-surgical patients as well?

Changing codes just to change codes does not help anything. CPT coding should reflect what interventions you are using and reflect the intent of the definitions and the intent of the CPT codes. For ICD-10 codes, The medical diagnoses that resulted in the impairments you are treating should be and stay the primary codes. Any comorbidities that affect the episode of care because the affect, the type, amount, frequency, and duration of PT for that episode should also be captured.

We had an incident where it became clear to our PT that the patient was having a medical crisis. Our PT was able to get the patient’s doctor on the phone, and the doctor decided we needed to call EMS. Are there any CPT codes we can bill regarding this? 

Any time you spend with the patient assessing them to decide on treatment during a session should be captured by billing the CPT code for the hands-on service that you were preparing to

deliver. The minutes of pre-hands-on assessment for therapeutic activities would include looking at the patient, taking vital signs, calling the doctor, and observing the patient. Bill for those minutes in 15-min increments but you have to document all those things to demonstrate the professional time you spent.

Which code do you use for home exercise versus therapy for speech therapy? 

You should include that time as part of the coding for services you delivered that day. There are no codes specific to Speech home exercises or follow-through.

Would an eval and therapy on the same day require an XU or 59 if the eval and rx codes are used on the same day? 

The NCCI edits are clear that most of the 15-minute treatment codes require the 59 modifier when ther re-evaluation codes are billed. Most treatment codes used with the evaluation codes do not. See the current NCCI Procedure-to-Procedure edits: https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-procedure-procedure-ptp-edits

Why am I getting denials from Humana if the ICD-10 code is an R-code? 

There are a number of Excludes 1 and 2 edits and Mutually Exclusive Edits in the R code chapter of ICD-10. Whenever you pick an ICD10 code, you should look it up and read the notations so you know what codes you cannot bill it with. 

Do you suggest adding all major comorbidities or ones that are musculoskeletal/neurological only? Include any comorbidities that may affect the episode of care by changing the type, intensity, duration or frequency of the interventions you intend to use. 

Does UHC still want the 59 modifier to designate non-overlapping services? CMS has recently wanted XE instead. Seeing more denials from UHC when services such as gait training & therapeutic activities are performed - even with 59 modifier. UHC does not follow the current procedure-to-procedure NCCI edits. CMS still states that the 59 is the appropriate modifier to attest that the services were delivered at separate and distinct times in a treatment session. For moce information, check out this fact sheet on the use of the 59 and X modifiers. 

We are curious if you have any insight on a therapy charge denial we are receiving from UHC and its Medicare Advantage plan.  Code 97116 is being denied as “not paid separately”.  Could it be the "reeducation of movement" and gait training? 

Insurance denies 97140 for mutually exclusive, cannot be performed together in the same setting or on the same day as 97012, even with modifier for separate time. These are part of the NCCI edits. Check the procedure-to-procedure edits: https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-procedure-procedure-ptp-edits.

What is the rule for Medicare with using the initial eval code and a splint training code when use splint training code if splinting is part of session? 

Not all MACS cover the splinting CPT codes, so check their medical policies. Orthotic training code 97760 can be billed with any evaluation.

Thoughts on the use of 97535 in outpatient orthopedics? Any worries about red flags? 

No. This code can be used regardless of patient diagnosis.

What about 97750? Should we be using this code for progress/recertifications? 

No. It is for standardized testing.

Can you provide more info about PT being able to diagnose in regard to ICD 10 codes. How specific can we be with a direct-access patient? 

A therapist cannot typically provide a tissue or system-level diagnosis. Only providers who are licensed diagnosticians in a state can provide a descriptive diagnosis only, e.g., Low Back Pain, Difficulty Walking, etc.

Is Anthem now requiring start and stop times for certain CPT codes? 

Yes, they are. 

Does the diagnosis for what is surgically repaired need to be coded with the aftercare code? 

Yes, it does. 

Documentation

How are we able to encourage therapists to change their documentation for treatment? We have therapists who are billing the same treatment for many sessions at a time. When is it a red flag for therapists to repeat their treatment? 

Therapists should bill for the services delivered based on the definitions of the CPT codes. Billing certain codes because they pay more that are not reflected adequately in the treatment notes will result in denials or recoupments.

How do other providers deal with front-end denials for dx codes that shouldn't be billed together if that's how an MD sent in the referral? 

It is the therapist's responsibility to bill the appropriate codes based on balancing the use of the codes provided and the ICD10 billing guidelines.

How do we handle showing progress for infrequent attending patients, i.e., patients who come once a week or every two weeks?  The progress note after 30 days will only have about 2-3 treatment sessions.  Even with the patient being compliant with their HEP, sometimes it is difficult to find meaningful improvement. 

The progress note is “at least every ten visits.” The 30-day requirement was changed several years ago.

If you’re charging a cash rate for TDN, can you treat it like a timed code (i.e., $30 for 15 min, $60 for 30 min, etc)? Or must you treat it like an untimed code even though several insurances don’t reimburse for it? 

If you use the dry needling trigger point codes, they are untimed codes. If it is a noncovered service for a payer you may collect from the patient. If it designated Not Medically Necessary/Investigational, you cannot bill the patient if you are a provider for that payer. 

Is it worth it to see a patient (outpatient in the home/mobile practice) for less than 53 min? My clinic has been doing 4 units across the board. 

Your documentation must always support your billing, whether you bill one or four units of service. 

Does the expiration of telehealth apply to physical therapy, occupational therapy, and speech-language pathology? 

Assuming you are referring to the Medicare Part B coverage of telehealth services, coverage ends at the end of 2024 unless Congress takes action.

Is dry needling covered by any insurances for physical therapy? 

Yes. You should call and verify coverage before billing.

When a commercial insurance plan is primary and Superior is secondary, do you have to bill Superior knowing that the primary is paying more than Superior allows? 

If a secondary covers an amount less than the primary, the secondary will not pay. You typically have to get that denial of payment in order to bill the patient for the unpaid share. 

In acute care, are folks obtaining prior auth for the therapy eval and treatment after a total joint when the payor is an MA plan?  

Since this visit is registered as an OP visit, hospital departments have to get authorization for MA plans that require prior authorization.

Does CARF accreditation improve anything for PT, OT, or SLP clinics?  For example, is reimbursement increased with this accreditation? 

No, it doesn’t increase reimbursement. 

When billing for direct access patients, what is required in the Physicians boxes? 

There is nothing required for the Physicians box.

We have only one NPI number for our therapist at a hospital and we can only bill with that NPI number. Is this still OK for outpatient therapy on campus?

Yes, this is acceptable.

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