Billing & Coding

Centers for Medicare & Medicaid Services (CMS) is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.”

Be sure your billing staff is aware of the modifier changes!

The primary issue associated with the -59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:

  • Different encounters;
  • Different anatomic sites; and
  • Distinct services.

 The -59 modifier is:

Medicare Quarterly Provider Compliance Newsletters are an educational tool designed to provide education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Program. It includes guidance to help health care professionals address and avoid the top issues of the particular Quarter.

Joint DME MAC/PDAC Publication

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have evaluated the MyoPro® upper extremity assist device and determined that it falls within the Durable Medical Equipment (DME) benefit category. Claims for MyoPro® should be submitted using the DME miscellaneous code E1399.

In the case of collagen dressings coded A6021A6022

Unsure of the date of service to bill on your claim form? The date of service for custom-made orthotics and prosthetics is the actual date the beneficiary receives the item. Do not use the date the item was ordered when billing Medicare.

Local Medical Review Policies (LMRPs) were converted to LCDs. This was done as a result of the Benefits Improvement and Protection Act of 2000 (BIPA 2000). The difference between LCDs and previously written LMRPs is that LCDs contain only reasonable and necessary conditions of coverage as allowed under section 1862(a)(1)(A) of the Act. LMRPs may have also contained other information such as coding and payment guidelines. Coding and payment information that is not related to section 1862(a)(1)(A) is not contained in an LCD; contractors communicate such information in related articles.

Medicare understands that there are individuals who may not meet the diagnostic criteria for substance abuse, but who are still at risk. To help identify these individuals and take steps to keep them from reaching the level of abuse, Medicare has established a program called the Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services.

Anyone who uses modifier 59 needs to be aware that due to problems with the incorrect usage of this modifier (which by the way is also revised for 2015,) CMS has added four new HCPCS modifiers. An announcement by CMS stated that "CMS is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.” 

These new codes are:

In 2013, CMS initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated on the date of service. CMS subsequently discovered that some of the data used was incomplete. Since some of these recoveries might have been erroneous, CMS initiated refunds. Most of the incarcerated beneficiary erroneous overpayment refunds were issued before the end of December 2013, with some subsequent refunds on situations that had been appealed. The process CMS used to expedite the refunds precluded the issuance of a detailed remittance advice (RA).

After a claim has been submitted and a reimbursement decision has been made, you or your billing agent receive a Remittance Advice (RA). The RA is a notice of payments and adjustments that the MAC produces as a companion to claim payments or an explanation when there is no payment. It features valid codes and specific values that make up the claim payment.

Some of these codes may identify adjustments, which refer to any changes that relate to how a claim is paid differently from the original billing. There are seven general types of adjustments:

1. Denied claim;

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