Medicare Compliance & Reimbursement

Remember to use modifier 59 to unbundled services.

The world of National Correct Coding Initiative edits now includes outpatient rehab services. Providers can follow this expert advice to ensure that they handle these changes with confidence--and protect their payments.

This means providers cannot bill some multiple therapies to Medicare on the same day for the same patient, unless they use the right modifier to unbundle the procedures. And if a provider is not watching closely, the new NCCI coverage will cut into its reimbursement for services reported to Medicare.

Currently, the NCCI edits affect only PTs and OTs in private practice and hospital outpatient departments with bill type 12x and 13x, notes Todd Bean, president of Preferred PT Billing in Beverly Hills, Calif. Therefore, these changes will primarily impact skilled nursing facilities, comprehensive outpatient rehabilitation facilities, home-health agencies providing Part B services and other outpatient therapy providers. To properly unbundle a service, providers should refer back to their plans of care, says Joanne Byron, president and CEO of Facility Health Care Consulting Solutions in Hickory, NC.

For instance, the care plan calls for a facility to provide group therapy for all of its knee patients twice a week and then work individually with those patients three times a week.
 
Some of those patients might have individual and group therapy on the same day, but as long as the plan of care identifies the group and individual therapy separately, a provider should be able to put a 59 modifier (Distinct procedural service) on the individual therapy code (such as 97110, (Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) and get paid for it, Byron says.