Blog, Chirosecure Live Event October 18, 2022

End Modifier Denials

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Hey, welcome everyone. It’s another edition of Chiro Secure’s Show. Getting your practice to grow without being stressed, if you will. That’s how I like to think of it. I’m your coding and billing expert, Samuel Collins. I’m the coding and billing expert, of course, for the HJ Ross Company and our service, the network where we’re there to always help.

But I also work with ChiroSecure as well as many state associations and others. I’m making sure you have your coding and billing correct. And one of the things that we have to discuss, and of course this has come up a lot, particularly for those calling in on the network or seminars I’ve been to is Sam, I’m getting denials about modifiers and are there some new ones?

What’s going on? Cause I’m having trouble with the 25 and when do I use the 59? So let’s talk about how to end modifier denials. Fix your claims and when you need to use them. Let’s make this relatively easy and painless. Follow this along and you should end all of your issues with denials for modifiers.

So let’s go ahead and go to the slides. Let’s take a look at what we’re dealing with. Of course, as always, here is our company, email or company website, HJ Ross Company. Go there. We’re always gonna be your portion to help you and do better with your claim. So let’s talk about what’s been occurring a.

I’m getting denials, Sam, because it says on the e o I’m missing, or an improper modifier that says C P T four and hcpcs, and I’ve had people going, What does that really mean? It means obvious to what it’s stated is you’re missing a modifier of some type. Now the confusion is people wonder wait a minute, what’s the difference between A C P T modifier and a hipp picks modifier?

A C P T modi’s usually gonna be numbers. And like 25 or 59 hcpcs are gonna be more similar to letters like the excess or the gp. And that’s often where there’s confusion. Here’s the tough part though, For many of us, you send it in, it comes back like this, and you call them and say, Hey, you’re saying I’m missing a modifier.

What modifier is it? You know what their answer will be? Oh, we can’t tell you that. And the reason of course they can’t tell you is because it’s not that they can’t or don’t know, but by doing so would be like they’re doing your billing and they have to make sure you understand it. So this is where we come in and Frank, this is why there’s continuing education as my dad always put it to me.

This is why we call it a chiropractic practice. Not a perfect cause. We’re always learning something. So let’s talk about, one of the big issues that’s gone on is this so called always therapy modifier or modifier gp. This is when you’re gonna be using a lot more, particularly with certain carriers when it comes to physical medicine or physical therapy codes.

This has been transitioning in for the last several years, I wanna say since 2020. United Healthcare is required, but I’m finding more and more payers are, and I wanna talk to you about which payers do. In which don’t because don’t be. Just because you use it with one payer doesn’t mean you use it with another, just like modifier at is used for Medicare, but no one else.

So this is called a level two hick modifier, and this is that difference of the number modifier to a letter one and where you gonna use it according to C PT it says, or CMS, it’s called Always therapy. Anybody think? What do you mean by always therapy? What does GP mean? It’s when you have a therapy panel of care, whether it’s done by a chiro, a physical therapist, occupational therapist, or speech therapist for that matter.

You’ll see the modifiers GP go, or gn. The GP is one for physical medicine. Now, that’s the one we would use in the chiropractic profession because we are doing physical medicine services, not physical therapy, cuz technically that means a physical therapist. But under that physical medicine plan of care go would be for an occupational.

The. GN would be for a speech therapist, though I think we might get by with using the others. The one we’re always gonna use is gp. So where do we use this On any code that is a physical medicine code or sometimes we like to use the term physical therapy. I don’t like to use the term physical therapy to not confuse because physical medicine are the codes that are physical medicine services, modalities and procedures.

And remember, they’re not owned by physical therapists. And I think that’s often the. We hear people say physical therapy and that’s, no, it’s not a physical therapist. It can be done by anyone within scope, including a chiropractor, and includes all the things from simple modalities all the way through therapeutic procedures like exercise, therapeutic activity, and so forth.

So who requires it? United Healthcare. Is definitely one. So if you’re billing United Healthcare, and remember, that means any of the affiliates of United Healthcare. So that’s gonna include Optum Health and umr. So anyone within that is gonna require a GP on a physical therapy code or physical medicine.

If you don’t include the modifier, automatically denied. It doesn’t change the price, it just indicates it’s a therapy protocol. And to pay it. Now the weird thing is you would go, don’t they already know it’s a therapy? I know that is weird, but it’s just one of the requirements. Yes, we have to have it.

It also includes the va. So now many of you on the East Coast in particular, you’re well aware that Optum does manage the va. So therefore it would apply there. But realize it applies all over for VA claims. Even for those of you billing through Try West, and that’s gonna include the state of Texas and anything west of Texas, if you will, would include try West.

Now let me be clear. I said try West. Not Tricare, and that’s for VA claims Optum as well as try West Anthem. Blue Cross and Blue Shield have been required. So if you’re in a state that’s using Anthem, which state doesn’t, you are gonna now require the GP on therapies to those. So this is gonna include states like New York, New Jersey, Florida Illinois and so forth are gonna require, but again, it doesn’t change the price, but it means it’s under a therapy plan of care.

Now here’s something weird because for California provider, It’s for Blue Cross of California, not for Blue Shield. So here’s one of the things you have to remember. I just said Anthem, which is conglomerate, but remember in California they’re separate Blue Cross and Blue Shield being separate. It means for Blue Cross claims, yes, but a GP.

Blue Shield. Do not. Now, of course you’re thinking, God, what a hassle. I get it. But know the difference between the two. Now you might be thinking if these require it, why don’t I put in all the others? Do not put a modifier on plans that don’t require it. So these would not be applied to Aetna or Cigna.

But these plans alone, this includes Medicare. Made me think Sam, come on. Medicare does not cover therapy. You’re right, it doesn’t. Not for chiropractic. At least not now. Hopefully in the future. Nonetheless. In order to get a proper denial for Medicare, you have to include the GP modifier on any therapy code.

Again, if you don’t have it automatically come back. So make it a simple rule. United VA Anthem, Blue Cross Blue Shield are specific to California. Blue Cross of California or Medicare require a gp. Is that hard? No. It’s just one of the things you have to learn and know. Remember when we switched to the G 0 2 83 for electric stem for United?

It’s just one of those things a little different for them. So how do we do it? Here’s an example. Notice. 97, 5 30 and 97. 1 24. Both being physical medicine codes. Both get a gp. Now you’re gonna notice something unique here. There’s an XS on the massage. Why is that? Of course we’re trying to show it’s a separate service, but we’ll talk about that in just a moment cuz that too is a hick mofi that we’re gonna need.

So let’s go back GP on therapies for those payer. Here’s one though, and I get this quite a bit, and this has come up a lot recently. In fact, I’ve been on a lot of blogs for the American Chiropractic International and other state associations, and we’re finding a lot of issues of denials of e and m codes.

E and m codes, of course, are separate and distinct and should be billed on an initial visit of a patient and a re-exam about every 30 days. And in order for us to demonstrate it separate, we have to put Mofi 20. But even when we do, we’re getting this type of denial back. It says the service build is part of a global service and not separately payable.

And you’re like, Gimme a break. That’s why I put the 25. If you’re not putting the 25, that of course would be the reason why. So let’s make sure you are putting a 25. Why the 25 modifier is to indicate that the evaluation done here is separate and distinct or above and beyond the exam associated with treatment.

Remember the adjustment, or actually any therapy code has a little built-in. Pre-service assessment, pre and post service. So by example, on a first visit, when you see someone, obviously you’re gonna do an exam that’s separate, put a 25. But what about a follow up when the patient comes back and say, Hi, Mr.

Jones, how are you feeling? Is that better or worse? A little review of the chief complaint and how it’s changed will be considered part of the treatment. Then the assessment may be range of motion, leg check, palpatory finding. That’s part of it. We adjust, maybe do a little counseling, that’s all included.

That’s part of it. But when it goes above and beyond, that’s when we put the 25. So here’s an example. Notice just simple. When you bill an adjustment, put a 25. In fact, let me make real clear, if you’re billing any therapy with an exam, The exam will require the 25 mofi, but what about a claim where you put the 25 and they still reject it and you’re gonna say, Wait a minute, what’s going on?

So let’s take a look here. Here’s a letter, or at least a format for you to follow. You’ll notice here it says, This letter is in response of your denial of the e m, that it’s already included. So let’s take a look at the paragraphs I have with red. It says, It is reported in the manual, meaning the CPT manual 2022 Edition.

Page 8 39. So we’re very specific that the CMT procedure includes a pre-service and post-service manipulation assessment. However, the evaluation management service preferred on this date was not routine. It wasn’t just one done every day, but every 30 days or a new condition. And it says the evaluation and management service provider was separately identifiable.

Evaluation management service above and beyond the usual pre-service and post-service. The separate distinct nature was indicated cuz on the 1500 form we put a 25 come on, you know better. We put the 25 on here and it says we’re gonna send with it. And this is what I would do is send a copy of the exam to say a detailed in the separate exam was necessary and beyond the scope of the pre manipulation assessment, send a copy of the exam.

Unfortunately, we’re having to do that with some payers. What a. That should be something they do regularly and not give an issue with, but I’m finding a few. So if you’re seeing this a lot, this would be a way to respond. The other thing I would suggest to do is check with your local state association and see if there’s a lot of us that are having that problem.

Cause what I always like to do is bring this type of thing to the insurance commissioner. Because these are things they go after. A one-off for one doctor is one thing. But if we’re bringing in hundreds or thousands of claims done by chiropractor, this is happening. We can get some changes there for them to stop because it should be payable.

In fact, that’s why we point out it says it right on page 8 39. Read the book. Give me a break. Here’s another one with modifiers, so that can be a problem. I know you all like to do, or a lot of offices do a lot of soft tissue work, massage manual therapy, but this even. Neuromuscular education, and this is under what’s called the CCI Edits or Correct Coding Initiative.

And this is where it talks about what codes can and cannot be built together. Now, I wanna highlight this and state, I don’t agree with this. I think this is a vote against chiropractic to some respect, but here’s what it says. Physical medicine and rehabilitation services described by the CPT codes 97 1 12 nervous education 97 1 24 massage and 97 1 40 are not separately reportable when performed in a spinal region undergoing cmt.

So in order for this service to be paid separately, we have to indicate that it’s done to a separate area, and that’s where the modifiers come in. When you are billing, massage, or manual therapy, the modifiers you have to have is one or the other, either 59 or excess. Frankly, one is not actually better than the other.

Excess in theory is more correct because it says specifically a separate area, but I don’t find that it really makes much difference as long as you have it. So here’s gonna be the rule. If you’re billing one of these service. and it’s a separate area. You have to put that modifier. But remember often just putting the modifiers not enough.

Cuz I see offices, they build out a cervical diagnosis and of course they’re manipulating the cervical and they’re doing manual therapy or massage to the cervical. Is that a separate area? It isn’t. The 59 may say it’s a separate area, but it’s not. So we have to make sure, is it really distinct because it’s a separate area, That’s what 59 and excess indicate.

If it is not, we’re gonna have a problem. So here’s how you do it and correct it. Make sure you demonstrate to them it’s a separate area. By doing that, take a look at this claim. This is a typical 1500 form and you’ll notice diagnosis A and B. Diagnosis A and B are cer. Diagnosis, C and D or lumbar notice 98.

Nine 40 has a B indicating the adjustment went to diagnosis, A and B, meaning cervical and the massage having excess separate has C and D. What is that indicating that yes, the massage was done to the low back manipulation to the neck. Is that a separate, distinct area? You bet payable. Now what if you’re not doing a separate?

Therein lies the rub. So be careful in order for this to be payable, it’s not enough just to have the modifier, but make sure you got a separate area and do so by doing diagnosis pointing so they don’t have to send you back for information. Let me see your notes, which shows the difference. Always try to give me a code for a separate area.

Now, of course, another area that we’re into problems with people was always scared of Medicare. Medicare is simple. Understand how it works. If you’ve never been to a good Medicare seminar, come to one of. Most people make this too hard and Medicare should be one of our better payers. Frankly. What does Medicare require though is it’s unique.

There’s four modifiers for Medicare that we use and once you understand how they work, not that complicated, but they are unique to Medicare. So the first one is modifier at, and you’ll see here a 9 8, 9 4 oh has an at. What does that mean? It is active or corrective care. In fact, I would often say at means pay.

When you bill Medicare, if you do not put spine manipulation with an at, it’s an automatic denial because they’re saying it’s not medically necessary. You said so by not having it. So what modifiers should go on? Anytime there’s a manipulation to the spine and it’s corrective to Medicare at, if you forget to put it automatically denied.

Now, another modifier for Medicare is modifier gy. Now GY is the modifier that says it’s an excluded service. If you think of it, Excludes everything but spinal manipulation. I mean for now. So therefore, what modifier would go on? Any code except spinal manipulation? Gy. So here’s a simple rule. If it is not spinal manipulation and bill to Medicare, what do you have to put on it?

G y. So you’ll notice this example exercise as well as the exam. Both haves applied to it. Now you’re gonna notice, Hey, wait a minute, Sam, I noticed the 99 2 13. 25. Sure the 25 is because there’s treatment the same day, so we still need that bear of mind. You can put four modifiers, you’re not limited to two or one up to four, and then you’re gonna notice, hey, wait, but exercise is not covered.

Why’d you put a gp? Let’s go back. Remember, GP is the modifier for physical medicine, even including Medicare. So most codes are gonna require two modifiers for us, particularly if it’s an exam or it’s going to be a physical medicine service because we’re gonna need the GY to show it’s. The GP to indicate that it’s physical medicine.

Now, quick note for Medicare, are you required to bill Medicare for things they don’t cover? Actually, no. Medicare frankly doesn’t care about things they don’t cover. However, maybe you want to bill it so you get the patient to get a denial or for their secondary. If your patient has no secondary, I would probably just explain to them, Hey, it’s not.

That way they pay outta pocket then going through the hassle of billing, but you can’t. So that’s the at and g y. We did talk about the gp, but there’s another one for Medicare that people often get confused. What about a patient that says, Hey Doc, I’ve learned that coming in once a week or every two weeks just feels good.

It makes me feel better. I don’t worry about having back pain. So I’d like to do adjustment schedule like that. F. However, of course, that’s gonna be considered maintenance when it’s Medicare. Now, for maintenance to Medicare, we have to have the patient sign what’s called an advanced beneficiary Notice that’s special form by Medicare, of course.

And when they sign the form, that means we put a GA on it. But let’s understand. GA technically means they sign the abn, but with the ABN is indicating that it’s not covered. So the GA automatically means patient respons. Once it’s patient responsibility, patient automatically owes. Now we may bill it to Medicare, so the patient gets a denial, but otherwise, just non payable.

And I wanna highlight, not hard. If it’s maintenance, put a ga. Don’t find it. If you know that Medicare is not gonna cover more than 15, 20, or 30, depending on the severity of the condition, put them on maintenance once you hit that point. Because if you don’t put the GA and Medicare denies it and you appeal now, if you win the appeal, great, but if you don’t win the appeal, you can’t charge the.

So error on the side of, maybe it’s not gonna be covered. Cuz let’s face it, I think chiropractors think everything should be covered. Medicare thinks nothing should be covered. I’m exaggerating both ends of that. But you get where I’m going now. One quick note though. Here’s a good question. Can I charge my regular rate?

When Medicare is not covering. So I wanna make clear, take a look at this Medicare Claims Processing manual SEC section 50.9. So long as you’ve properly done an abn, it says here the charge may be the healthcare provider or supplier’s usual and customer fee for that item or service, not limited to the Medicare fee schedule.

So in other words, Medicare fees do apply when Medicare is. If it’s out of pocket or the patient is paying, you can charge a regular rate. Now, that’s up to you. You could continue to charge this at the Medicare rate if you like, but bear in mind you can charge a regular rate when not covered and or maintenance by Medicare.

You might be thinking, Hey Sam, if I’m not sure if Medicare is gonna cover, can I submit an AT with the ga? Dude? Can I do. The answer is no. It says here, Chiropractic claims submitted with a modifier at indicate that the provider is supplying active corrective care. The at modifier may not be submitted with services that meet the definition of maintenance.

It says, and this is taken directly from Medicare at and ga modifiers on the same line. We’ll be rejected. Rejected claims do not have appeal rights. So if you do that, you’re. Nothing. You can’t collect from the patient, so you really have to make a decision. Do I think it’s corrective or is it maintenance?

If it’s maintenance, the ABN and ga, only if you think it’s corrective at now, you might think, Hey, wait a minute. How do I know how many visits, what I’m gonna suggest? Have you ever been to a really good seminar on Medicare like ours that talks about the hierarchy of diagnosis? Which codes are less than 12 visits, which are 18 to 24, which are 30?

There’s a hierarchy of diagnosis to know, and I would say for most of you, most Medicare patients probably are between 20 and 30 visits a year on average. Not all, but on average, and some may even be more. This is where I think we miss out, cuz people are stuck on it’s only 12 visits. It’s more than that.

So make sure you’re doing it right though. Is it corrective or is it maintenance? Make the decision. Now here’s a weird. Obviously a lot of us are dealing with Medicare Advantage plans. In fact, this is the time of year everything’s transitioning. Medicare Advantage plans work just like Medicare. They are build just like Medicare, subluxation, secondary, and modifiers.

Now, I will highlight they don’t use the GA modifier, but they do use the gp. They do use the at. However, here’s a weird one. If you run into a Humana Medicare Advantage plan, they require not an at, not a gp, literally modifier 97. So that’s one of the ones you just wanna put in the memory bank and say, I remember Sam saying that when I get a Humana Medicare, it’s modifier 97 again, Is that really hard?

No. But it’s just, if you don’t know it, it’s really hard. So once you understand the differences, not a big deal. Here’s a couple other ones though that may come up and I had people say my Medicare patient’s in hospice, Can you still treat them? Actually you can, but when you do, you have to use modifier GW in addition to at, and that’s just to show a hospice.

If you don’t, it’s coming back because hospice is responsible for the patient’s care. But if they’re getting chiropractic while part of it and realize this could be someone that’s home. You could be at hospice without being in a hospital, it’s just modified gw. Or how about this one? I have a lot of doctors calling me and saying, I’m gonna take a three week vacation or a month, and I’m gonna bring in a vacation relief Doctor, can you do that?

You can in most instances without issue. What you have to do though, to show it’s a locum tenants. Now, this doesn’t mean it’s not bill under your name, It’s still built under you, just like it would normally, but the visits that were under the locum, you put a Q six modifier on the therapy. Or on the treatment code that just shows there’s a locum, Their name doesn’t appear on the chart, or excuse me, in the on the claim, but in the chart notes only.

But that’s certainly allowed, and that happens quite a bit. If you’re ever gonna leave out for a extended time, wanna keep your office open? There’s doctors that specialize in this that come in and work two, three weeks, sometimes longer, depending if you have a sabbatical or an illness. And here’s one more.

I’ve got a lot of Multidiscipline offices now mdc, but remember this could include nurse practitioner. It may include PAs and so forth. CMS has two different modifiers. Now, whether the services are being done by a PTA or an occupational therapy aid. If it’s a pta, you have to put on therapies. Now, cq, if it is an occupational therapy aid co, now I may think, why do I have to do that?

It’s just show that there was an a doing it. There’s nothing wrong with a doing. But when it’s not the licensed provider, meaning the physical therapist directly, we put these modifiers because what they do is pay 85%, and it’s the same way that a PA doesn’t get the full pay that a MD does. They get 85%.

Same thing here. Now, for many of you, I would suspect probably you’ve got a multidiscipline where the PTs doing the work alone, but just in case, remember, this does apply to make sure we’re compliant. Now, are these very. No, take some time if you watch the show and go, Ooh, that seems like a lot rewatch it.

Remember, you can watch this over and over. This is gonna appear on our website. It’s gonna appear on the ChiroSecure website, but it’s gonna be a place for you to always go back and say, Wait a minute. What did Sam say about that 97 or qw, or whatever modifier I seen. This is a place to look for. We’re always gonna be a resource.

This is the HJ Ross website. We update a new section there, All the new codes for ICD 10, which I did a show on that. So if you don’t. Go back and look for a show there. We’re gonna be updating soon the stuff that’s changing for 2023 for C P T. Remember, HJ Ross is part of ChiroSecure. In this way, we’re symbiotic.

We work together. We’re here to help you get paid. You wanna get an expert in your office for less than a thousand a year? Hire my service. Just go right here to our website, take a look to see what we will do, and it gives you unlimited access. Call, email, fax, zoom. We’re always here to make sure your claims are.

And paid properly. Next week will be Sherry McAllister. Everyone thank you for this time. I’ll see you when I come back.