95992 Denials Epley Maneuver Need help

April 26, 2011

Hi group:

I had read on the list serve that CMS had approved this therapy code for

payment. We do a lot of Epley Maneuver training, so I billed the code with

appropriate modifiers, only to get a denial. When I called Palmetto, our

intermediary, I was told " independent therapists " cannot charge this code.

The denial code is PR170. " Payment is denied when performed/billed by this

type of provider. "

I have been to the CMS website and have learned that the code is a

" sometimes " code with a detailed explanation of what a " sometimes " code

means. I've retyped the explanation below. I really can't figure out why

Palmetto won't pay the code. Does anyone have an explanation? Is someone

better at Medicare-Speak than I am?

And now that this code has been denied, what should I be billing for the

therapists' time?

" CMS:

These HCPCS?CPT codes (95992 is listed) sometimes represent therapy

services. However, these codes always represent therapy services and

require the use of a therapy modifier when performed by therapists.

There are some circumstances when these codes will not be considered

representative of therapy services and therapy limits (when they are in

effect) will not apply. Codes marked 7 are not therapy services when:

It is not appropriate to bill the service under a therapy plan of care, and

They are billed by practitioners/providers of services who are not

therapists, i.e., physicians, clinical nurse specialists, nurse

practitioners and psychologists; or they are billed to fiscal intermediaries

by hospitals for outpatient services which are performed by non-therapists

as noted in Note E above.

While the " 7 " designates that a particular HCPCSCPT code will not of itself

always indicate that a therapy service was rendered, these codes always

represent therapy services when rendered by therapists or by practitioners

who are not therapists in situations where the service provided is integral

to an outpatient rehabilitation therapy plan of care. For these situations,

these codes must always have a therapy modifier. For example, when the

service is rendered by either a doctor of medicine or a nurse practitioner

(acting within the scope of his or her license when performing such

service), with the goal of rehabilitation, a modifier is required. When

there is doubt about whether a service should be part of a therapy plan of

care, the contractor shall make that determination. "

Viel, Office Manager

Mt. Eden Physical Therapy Center

19845 Lake Chabot Road, Suite 205

Castro Valley, CA 94546

FAX

www.mtedenpt.com

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April 26, 2011

Hi ,

I believe that it has a status B indicator code. As far as I know it does not

matter whether it is on a claim alone or in conjunction with another, separate

payment will not be made and the patient cannot be billed either.

From: Mt. Eden Physical Therapy

To: ptmanager

Cc: Sims ; Viel ; Cali Phan ; Candy Salinas ; Debbie Prusack ;

Donna Meyer ; Jay Mehta ; Jill Watase ; Weir ; Lorelei Valencia ;

Rayndles ; Robin Casagranda ; Sandy MacLean ; Sandy Schall ; Sherry ;

Simon Gibson ; Watase ; Vicki McDill

Sent: Tuesday, April 26, 2011 12:25 PM

Subject: 95992 Denials Epley Maneuver Need help

Hi group:

I had read on the list serve that CMS had approved this therapy code for

payment. We do a lot of Epley Maneuver training, so I billed the code with

appropriate modifiers, only to get a denial. When I called Palmetto, our

intermediary, I was told " independent therapists " cannot charge this code. The

denial code is PR170. " Payment is denied when performed/billed by this type of

provider. "

I have been to the CMS website and have learned that the code is a " sometimes "

code with a detailed explanation of what a " sometimes " code means. I've retyped

the explanation below. I really can't figure out why Palmetto won't pay the

code. Does anyone have an explanation? Is someone better at Medicare-Speak

than I am?

And now that this code has been denied, what should I be billing for the

therapists' time?

" CMS:

These HCPCS?CPT codes (95992 is listed) sometimes represent therapy services.

However, these codes always represent therapy services and require the use of a

therapy modifier when performed by therapists.

There are some circumstances when these codes will not be considered

representative of therapy services and therapy limits (when they are in effect)

will not apply. Codes marked 7 are not therapy services when:

It is not appropriate to bill the service under a therapy plan of care, and

They are billed by practitioners/providers of services who are not therapists,

i.e., physicians, clinical nurse specialists, nurse practitioners and

psychologists; or they are billed to fiscal intermediaries by hospitals for

outpatient services which are performed by non-therapists as noted in Note E

above.

While the " 7 " designates that a particular HCPCSCPT code will not of itself

always indicate that a therapy service was rendered, these codes always

represent therapy services when rendered by therapists or by practitioners who

are not therapists in situations where the service provided is integral to an

outpatient rehabilitation therapy plan of care. For these situations, these

codes must always have a therapy modifier. For example, when the service is

rendered by either a doctor of medicine or a nurse practitioner (acting within

the scope of his or her license when performing such service), with the goal of

rehabilitation, a modifier is required. When there is doubt about whether a

service should be part of a therapy plan of care, the contractor shall make that

determination. "