Full Answer
What is the difference between CPT code 97530 and modifier 59?
CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block.” In other words, modifier 59 should only be applied “when two timed procedures are performed in different blocks of time on the same day.”
What is CPT code 97530 therapeutic activities?
What is CPT Code 97530 Therapeutic Activities? CPT code 97530 is therapeutic activities, using dynamic activities one on one patient contact by the provider to improve functional performance (real-life movements), each 15 minutes.
What are the therapy assistant modifiers for 97110?
Generally speaking, the therapy assistant modifiers apply when a therapy assistant provides more than 10% of a service (though of course there are some exceptions to this rule that you can explore here ). In this scenario, apply the CQ modifier to one of the two units of 97110.
What is the CPT code for group therapy with ultrasound?
For example: group therapy (97150) with ultrasound (97035); f. Any untimed evaluation or reevaluation code (CPT codes 97001-97004) with any other timed or untimed CPT codes, including constant attendance modalities (CPT codes 97032 – 97039), therapeutic procedures (CPT codes 97110-97542) and group therapy (CPT code 97150)
Does Humana accept modifier 59?
Humana's policy is consistent with the CMS changes. The Humana decision significantly reduces the instances in which a PT will need to append the 59, X, XE, XP, XS, or XU modifiers and will eliminate situations in which certain code pairs were prohibited.
Does Humana follow Medicare billing guidelines?
Humana is excited to announce that we recognize the new coding and guidelines for our Medicare Advantage, commercial and select Medicaid plans. When the AMA and CMS differ in their coding and guidelines, Humana plans follow the CMS guidance.
What is the CPT code for Humana?
This Medicare Advantage and commercial policy outlines how Humana adjudicates a charge for CPT code 99072.
Does Humana follow NCCI edits?
Humana expands incidental/bundling editing on a continuous basis. Updates are made to Humana's editing systems based on direction from the AMACPT, the National Correct Coding Initiative (NCCI) and other applicable codingstandards.
What is modifier 97 used for?
Modifier 97- Rehabilitative Services: When a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified healthcare professional may add modifier 97- to the service or procedure code to indicate that the service or procedure ...
How do I bill my Humana insurance?
Other ways to pay your plan premium Be sure to write your billing ID, found on the coupon or billing-related letter from Humana, on your payment. Call our Customer Care department at the number listed on the back of your Humana member ID card to make a payment or sign up for auto pay.
What is modifier 25 in CPT coding?
Evaluation and ManagementModifier -25 is used to indicate an Evaluation and Management (E/M) service on the same day when another service was provided to the patient by the same physician.
Does Humana Medicare accept consult codes?
Medicare no longer accepts 99241-99255, but other payers may....Table 1: Payer Reimbursement—Summary.PayerStatusEffectiveHumana Medicare (MCHMO and MCPPO)Does NOT Accept Consultation Codes01/01/1012 more rows•Oct 1, 2010
Does Humana Medicare accept paper claims?
Two ways to submit a claim. Valid National Provider Identifiers (NPIs) are required on an electronic claim submission and strongly encouraged on a paper claim submission. If a paper claim does not have all necessary NPIs, it may be denied or be subject to delays in adjudication.
What is the CPT code for respiratory therapy?
94640 – Pressurized or non-pressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device).
Which payers follow NCCI edits?
There are several payers that have adopted CMS National Correct Coding Initiative (NCCI) edits and have implemented them into their claim scrubbers, such as Blue Cross and UnitedHealthcare.
Can respiratory therapists bill Medicare?
Regardless of the setting, respiratory therapists cannot bill any insurer directly for their services. Standardized coding is essential for Medicare and other health insurance programs to pay claims for medically necessary services in a consistent manner.
What is CPT code 97140?
CPT description for code 97140 (manual therapy ) includes manual therapy and techniques such as manipulation, soft tissue mobilization or joint mobilization. Individual techniques should not be separately coded or billed since it is a time-based code. All techniques applied on the same date of service should be totaled into the time calculated for the code. This procedure may be medically necessary as an adjunct to other therapeutic procedures such as those represented by code 97110 (therapeutic exercises), 97112 (neuromuscular re-education) or 97530 (therapeutic activities).
What is the 97000 CPT code?
The CPT Codes 97112, 97110 and 97530 fall within the 97000 series of codes considered “Physical Medicine and Rehabilitation”. Originally OT and PT providers had exclusively used the codes. And many third party payors still call the 97000 series “OT and PT codes”. Since 2002 CMS has defined qualified vision rehabilitation specialists as – Optometrist, Ophthalmologist, and Occupational Therapist when under the direct supervision of OD or OMD. State and National legislations have shown that these codes are not exclusive to any particular group of providers as long as the provider is licensed to provide the services they are performing under their state laws. Some state Boards of Optometry specifically provide guidance for optometrists on this and some state boards do not. You should check your local state board for their position. Currently, the 97000 series CPT codes are used by MD, DO, OD, DC, DPM, OT, PT, & SLP providers.
What is the CPT section of rehabilitation?
The CPT section devoted to “therapeutic procedures” contains many of the CPT codes utilized by rehabilitation providers to describe the skilled, direct one-on-one component of treatment. These codes describe the bulk of hands-on, skilled care 0 provided by rehabilitation providers.
How long does modifier 52 take?
Modifier 52 should not be used for therapy services less than 15 minutes. At least eight minutes of a physical therapy timed service must be provided in order to use a therapy procedure code (i.e. 97140 – manual therapy techniques, one or more regions, each 15 minutes).
Can you bill for 97110 ultrasound?
Bill 1 unit each of 97110, 97116, and 97140. You are unable to bill for the ultrasound because the total time of timed units that can be billed is constrained by the total timed code treatment minutes (i.e., you may not bill 4 units for less than 53 minutes regardless of how many services were performed).
Is 97140 a manual therapy?
Thus, 97140 is for hands-on therapy only. Manual therapy includes the following: Manual traction may be considered reasonable and necessary for cervical radiculopathy. Joint Mobilization (peripheral or spinal) may be considered reasonable and necessary if restricted joint motion is present and documented.
Can a therapist bill a patient separately?
Therapists, or therapy assistants, working together as a “team” to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient.
When is modifier 59 reported?
Modifier 59 may be reported if the two procedures are performed in distinctly different 15 minute time blocks. For example, one service may be performed during the initial 15 minutes of therapy and the other service performed during the second 15 minutes of therapy. Alternatively, the therapy time blocks may be split.
When did CMS 1450 become effective?
Effective with claims submitted on or after April 1, 1998, providers billing on Form CMS-1450 were required to report the number of units for outpatient rehabilitation services based on the procedure or service, e.g., based on the HCPCS code reported instead of the revenue code. This was already in effect for billing on the Form CMS- 1500, and CORFs were required to report their full range of CORF services on the Form CMS-1450. These unit-reporting requirements continue with the standards required for electronically submitting health care claims under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) – the currently adopted version of the ASC X12 837 transaction standards and implementation guides. The Administrative Simplification Compliance Act mandates that claims be sent to Medicare electronically unless certain exception are met.
What is the purpose of the wheelchair management code?
This code was intended only to be used where a person has the capability to learn to maneuver a wheelchair independently.
Can a therapist bill outpatient therapy?
In the same 15-minute (or other) time period, a therapist cannot bill any of the following pairs of CPT codes for outpatient therapy services provided to the same, or to different patients.
Humana guidelines and best practices
For detailed information about Humana’s claim payment inquiry process, review the claim payment inquiry process guide (300 KB). (opens in new window) , PDF opens new window
Diagnosis coding documentation
Industry-standard diagnosis coding guidelines require a strict literal interpretation to the health care provider’s medical record documentation
1. The Scenario
A patient with patellofemoral pain seeks treatment. At the beginning of the patient’s appointment, the clinic PTA provides 13 minutes of therapeutic exercise (CPT 97110), after which the PT provides manual therapy (CPT 97140) for 22 minutes. Then the PT leads the patient through 15 more minutes of therapeutic exercise.
2. The Scenario
After recovering from a broken arm, a Medicare patient develops adhesive capsulitis of the shoulder and seeks treatment from a PT.
3. The Scenario
A Medicare patient receives a left total hip arthroplasty via a posterior approach and seeks post-op care from a physical therapist with a goal to discontinue the use of a straight cane with ambulation.
4. The Scenario
A Medicare beneficiary with Ehlers-Danlos syndrome is seeing an occupational therapist to help manage their joint hyper-mobilization. Recently they purchased a wheelchair (per their physician’s recommendation), which the OT plans to help train them on.
5. The Scenario
A Medicare beneficiary is seeing a PT for a case of upper-cervical neck pain that they believe is triggering major headaches. They mention at the beginning of their appointment that they think they’ve surpassed their therapy threshold.
Commercial Payer Denials and Appeals
- Anthem, Aetna, and Humana, however, have decided to deny providers use of the second column code (97530) as mutually exclusive, thus forcing providers to appeal the coverage decision and show their documentation. If you receive this type of a denial, then your billing team should abso…
Alternate Codes
- Alternatively, you can avoid the edit entirely by delivering interventions other than therapeutic activities (97530) when performing manual therapy (97150) during the same patient visit. These interventions might include therapeutic exercise (97110) and/or neuromuscular reeducation (97112). However, you cannot simply perform a therapeutic activity and bill it as a therapeutic ex…
Therapeutic Activities
- Definition: Direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes. Key words here are “dynamic activities” and “functional performance.” Think of “dynamic” as “big” body movements or multi-segment movements. Think of “functional” as meaning “real-life” movements—like lifting, carrying, squatti…
Neuromuscular Re-Education
- Definition: Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture and proprioception for sitting and standing activities. Therapeutic procedure, one or more areas, each 15 minutes. This code emphasizes specific feedback to the patient about the quality and/or specificity of instruction in movement, mechanics, posture, and balance, as well as facilit…
Therapeutic Exercises
- Definition: Therapeutic exercises to develop strength, endurance, range of motion, and flexibility. Therapeutic procedure, one or more areas, each 15 minutes. Granted, this is a vague definition, which makes it tempting to use this code for all movement interventions. And that’s exactly why it tends to be overused. Instead, only code for therapeutic exercise if the movement doesn’t meet t…
Advocacy Efforts
- The APTA has been working with Aetna, Anthem, and Humana for well over a year now to address their claim edit policies—and to push for reversal of the policies described in this article. Progress has been slow, but Aetna has indicated that it is monitoring appeal overturn rates to determine whether the policy should be rescinded. For this reason, it is essential that providers appeal thes…