Knowing when to bill for individual services in a group setting can be tricky. Here’s what to keep in mind.
Here are answers to every question you’ve ever had about Medicare Part B for outpatient rehabilitation services.
Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.)
Questions related to:
• Modifier 59
• Other Modifiers
• Advance Beneficiary Notice (ABN) of Noncoverage
• Contracts and Fee Schedules
• 8-Minute Rule
• Functional Limitation Reporting
• Cash-Pay Patients
How does WebPT help me bill better?
WebPT prompts users to apply modifier 59.
When WebPT detects that you have billed two codes that form a CCI edit pair, the system will alert you and ask whether you performed these services separately and distinctly of one another—and, therefore, should receive payment for both. If you attest that this is the case, WebPT will automatically apply modifier 59 to the appropriate code.
For WebPT Members
To activate this feature, please follow the steps below. Note that you’ll need to complete these steps for each insurance plan. We recommend applying this to commercial and government plans only (i.e. no workman’s compensation, legal/lien, and auto liability policies).
- Select “Display Insurance,” located on the left side of the WebPT Dashboard.
- Click “Edit” on the individual insurance for which you want to activate the feature.
- Once the insurance editing screen opens, check “Apply CCI edits”; then, select “Save.”
For Non-WebPT Members
If you’re not yet a WebPT Member, you can see this functionality and an array of other awesome features in a free, live online demonstration. Request one here.
WebPT tracks the therapy cap.
WebPT offers the Medicare Cap Report, which enables you to view Medicare beneficiaries’ progress toward the therapy cap and see whether therapists have affixed the KX modifier for those patients who have, in fact, exceeded the cap. In addition to tracking the therapy cap, WebPT alerts providers when a patient is:
- approaching the cap
- exceeding the cap (time to attach the KX modifier!)
- approaching the manual medical review threshold ($3,700)
- exceeding the manual medical review threshold
To learn more about the Medicare Cap Report and WebPT’s other compliance reporting and tracking capabilities, check out this blog post.
WebPT calculates the 8-minute rule.
As this blog post explains, “WebPT automatically double-checks your work for you and alerts you if something doesn’t add up correctly. All you have to do is record the time you spend on each modality as you go through your normal documentation process, along with the number of units you wish to bill. If those two totals don’t jibe, WebPT will not only let you know something’s off, but we’ll also tell you whether you overbilled or underbilled. That way, you can quickly identify and fix the problem—and thus, ensure accurate payment. Plus, you’ll have a detailed record of the services you provided on each date of service—something many local MAC auditors request to substantiate billing claims and processes.”
WebPT handles PQRS reporting.
WebPT is a certified PQRS registry. This means we collect PQRS claims data and submit it to Medicare on your behalf. We also have all the PQRS reporting requirements in our system, so depending on the Medicare beneficiary and visit, we’ll prompt you to complete the appropriate measure. Learn more about PQRS with WebPT.
What diagnosis code flows over from WebPT into my billing?
When you use WebPT, your treatment diagnosis is the one that is billed—not the medical diagnosis.
Billing for physical therapy services is tricky, time-consuming, and nerve-racking. After all, there are so many rules you have to follow, and it seems like those rules are constantly changing. That makes mistakes tough to avoid.
Today’s blog post comes from Geoff Elledge, WebPT Billing Specialist. Thanks, Geoff!
One of the primary reasons medical providers depend on certified coders is for their ability to maximize practice revenues. To do so, certified coders must understand how and when to use modifiers—and there are a lot—from the common sides of treatment, like right (RT) and left (LT), to the more challenging modifier 59.
The CPT Manual defines modifier 59 as the following:
“Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures [and/or] services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.”
Got that? Yeah, we know. It’s a bit dense and doesn’t seem the most relatable. But that’s because modifier 59 is intended mainly for surgical procedures, so the definition leans a great deal that way.
So how does modifier 59 come into play in the therapy setting? If you’re providing two wholly separate and distinct services during the same treatment period, it might be modifier 59 time! The National Correct Coding Initiative (NCCI) has identified procedures that therapists commonly perform together and labeled these “edit pairs.” Thus, if you bill a CPT code that is linked to one of these pairs, you’ll receive payment for only one of the codes. It’s therefore your responsibility as the therapist to determine if you’re providing linked services or wholly separate services. This will determine whether modifier 59 is appropriate.
Billing for one-on-one therapy and group therapy services can be tricky (so tricky you may need a bit of therapy yourself). You should never use one-on-one CPT codes if you’ve provided group therapy services, as doing so increases your risk of a Medicare audit. But what, exactly, are you allowed to bill? How do you even know if you’ve provided one-on-one or group therapy?
It’s a mad, mad, mad, mad Medicare world, and unfortunately, just about every regulation requires a modifier. If you apply the wrong modifier—or forget one entirely—then your clinic suffers decreased payments or flat-out denials. Even worse, if you amass enough modifier mistakes, you make your practice vulnerable to an audit.
As an entrepreneur, I’m prone to breaking rules and taking risks. But as a PT—and an ethical businessperson—I tend to adhere to regulations, because in those roles, risky moves often come with hefty consequences. So, what happens when the lines between growing a business and providing quality patient care blur—as they so often do in private practice?
No, by having your patient sign an ABN, you are acknowledging that you do not believe that the services you are providing are either medically necessary or covered by Medicare. If you have an ABN on file, you should include a modifier GA or GX modifier on your claim so Medicare knows to deny the claim and assign financial responsibility to the patient.
Greetings, WebPTers! First, let me say thank you for the opportunity to chat with you today about appropriate use of the 59 modifier in 2014. Even though we’ve been using the 59 modifier for some time now, there is still plenty of confusion and misunderstanding about when and how to use it. In fact, when we created our compliance plan, we listed use of the 59 modifier as a risk to be assessed and monitored.