Wiki PT denial 97001/GP, 97110/GP, 97140/GP

[glittersparklz]

Hello,

We received a denial from Medicare for PT services 97001/GP, 97110/GP X2, & 97140. The denial code states that payment for 97110/GP x2 & 97140/GP are included in the allowable for another procedure.

I have been researching CMS rules on submitting these codes together and am drawing a blank. Any insight would be greatly appreciated, thanks!

 

[mitchellde]

Typically you cannot bill the evaluation on the same day as the modalities. Check your CCI edits.

 

[glittersparklz]

Thanks Debra! Do you happen to have a link to the info you located? I cannot find anything that applies in the CCI edits.

 

[honeybee]

You probably need to apply functional limitation reporting info in order to get the claim paid. None of those codes are typically bundled but I suppose depending on your MAC they may want a 59 modifier on 97001. We do not usually need to apply the 59 when billing these codes together.

Missy Lupercio
Spooner PT

 

[glittersparklz]

Thanks Missy, I think that is the issue! Looks like the office forgot to add the functional G-codes

 

[mitchellde]

I read this many years ago in a newsletter from decision health. I always had issues getting reimbursement for an evaluation and modalities on the same day. Since I read the article I stopped the therapists from doing this and no problems since then. I have talked with many others that code for rehab and they also had the same problem every time they tried to bill an evaluation with a modality. But then again it could just be the modifies as suggested. Try that and see.

 

[kivbar16]

Anytime you have an evaluation (97001) or re-evaluation (97002), you must use Functional Limitation (G) codes. There should not be any other issue with your claim; only time you need a 59 modifier is w/ the re-evaluation code. (As an aside, you would also need G codes on every 10th visit.)