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CMS Compliance: Correct Coding Initiative & Medicare Part B Exception Process

  
  
  

CMS Compliance-Correct Coding Initiative-8 Minute Rule-Medicare Part B Exception Process

Therapists are responsible for compliance with the Correct Coding Initiative, the Medicare Part B Exceptions Process, and the 8 Minute Rule. These compliance regimens have complex guidelines on how “therapists” should apply modifiers or billing units to CPT codes provided.  Missing modifiers or incorrect billing units are errors that will result in denials.  These errors are costly both in terms of lost revenue and the time needed to research, re-bill, and recover that lost revenue.

Simple and effective tools are required to alert therapists when billing modifiers are missing from codes or if the billing units assigned to codes are incorrect.  Better still, quick and easy ways to correct these errors before claims are submitted will prevent denials and maximize Medicare Part B revenue.

Correct Coding Initiative Edits

The Correct Coding Initiative (CCI) requires a 59 modifier for CPT codes billed on the same day, for the same patient, or by the same provider.  The 59 modifier indicates that each code was a distinct and separate procedure.  By adding the 59 modifier, the therapist “attests” that the codes provided were not “unbundled” and may be billed together.  The 59 modifier is applied across all disciplines that treated the same patient on the same day with the same provider number.

Tips in managing the Correct Coding Initiative and applying 59 modifiers include:

  • Therapists should only be alerted that a modifier is required.  CMS views applying modifiers to codes automatically by billing systems as a “red flag” for review.  CMS states that the therapist must be responsible for applying modifiers to codes in their treatment sessions.

  • CCI edits are updated annually.  Your current provider should update these CCI edits for you in order to prevent billing errors and subsequent denials.

  • Therapists need a tool to alert them if “mutually exclusive” CPT codes are used.  These codes should not be used together on the same day for a patient.  If billed together, they will be denied.

The Medicare Part B Exception Process

The KX modifier is applied to CPT codes when the patient exceeds the annual Medicare Part B Therapy Cap, currently $1,870 for physical and speech therapy and $1,870 for occupational therapy.  By applying the KX modifier to a code, the therapist “attests” that they have clinical documentation to support and justify continued treatment above the Cap.  Consider the patient's diagnoses and the medical necessity of continued treatment when determining if treatments should exceed the Cap.

Tips in managing the Medicare Part B Exceptions Process and applying KX modifiers include:

  • Therapists should only be alerted that a modifier is required.  CMS views applying modifiers to codes automatically by billing systems as a “red flag” for review.  CMS states that the therapist must be responsible for applying modifiers to codes in their treatment sessions.

  • Med B Caps management tools should “link” to the patient’s ICD9 code diagnoses.  Certain ICD9 codes allow you to use the KX modifier automatically once the Cap is reached.  Others allow you to use the KX modifier if there is another ICD9 code on the claim.

  • CMS requires that KX modifiers be applied to all codes provided in the month the patient exceeds the Cap regardless of when the Cap is reached.  Failure to do so may result in denials.

The 8 Minute Rule

The 8 Minute Rule specifies a range of treatment minutes that must be provided to support the units billed for individual CPT codes or for a group of codes provided in a treatment session.  The rule will result in approximately 12 to 18 minutes of treatment time per unit for sessions with more than two billing units.   

  • The 8 Minute Rule guides therapists in reporting total time for their treatment session.  Codes with fewer minutes can be combined with the minutes of other codes to compute the number of units to bill on a claim.  Combine treatment minutes in a way that bills the codes with the most minutes.

  • In a 30 minute treatment session with 3 codes of 10 minutes each, the therapist should decide which two codes best represent the intent of the session.  CMS cautions therapists that codes selected for billing should not to be based on the highest dollar value.

CMS states that the therapist is responsible for determining the appropriate billing units for their treatment sessions.  Any Medical Record Review (CERT, MAC, RAC, etc.) will hold the provider and the therapist responsible for billing errors or clinical documentation that does not support the medical necessity of charges billed.  Ignorance of how claims are processed will not excuse the provider or therapist from such billing errors.

*****

CarePoint therapy management software includes simple and effective tools to alert therapists when billing modifiers are missing from codes or if the billing units assigned to codes are incorrect.  Our Activity Monitor and Med B Caps Report provide quick and easy ways to correct these errors before claims are submitted.  These tools will prevent denials and maximize Medicare Part B revenue.

Correct Coding Initiative-CMS Compliance-8 Minute Rule-Medicare Part B Exception Process

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