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PIP Alert

February 17, 2014

    Re: New DPRP Plan for Liberty Mutual effective 2-17-14

Liberty Mutual Decision Point Review Plan (DPRP)

EFFECTIVE 02/17/14 LIBERTY MUTUAL WILL NOW BEGIN USING CONSOLIDATED SERVICES GROUP (CSG, INC.) AS THEIR VENDOR FOR PROCESSING THEIR DECISION POINT REVIEW PLAN REQUESTS. ALL REQUESTS FOR PRE-CERTIFICATION AND APPEALS MUST BE FAXED-FORWARDED TO CONSOLIDATED SERVICES GROUP (CSG, INC.).
  1. All requests for Pre-Certification must be faxed over to CSG, Inc., at the following fax number: 856-910-2501. All pre-certification requests must include a completed Attending Provider Treatment Plan - Form A04-143 - which is attached, together with progress notes and testing results, if available/applicable. The Attending Provider Treatment Plan must be signed by the medical provider. The phone number for CSG, Inc.'s Pre-Certification Department is 877-258-2378.
  2. All Appeals concerning Decision Point Review Pre-Certification Requests (denial(s) of proposed treatment, testing, and/or durable medical equipment) are to be faxed over to CSG, Inc., at 856-910-2501. ** All appeals of pre- certification request denials MUST be appealed within 10 business days of the date of the denial of authorization for proposed treatment, testing and/or durable medical equipment. The appeal must be signed by the treating provider, must state the issue being disputed, and include supporting documentation. CSG, Inc., must respond to any appeal of the denial of authorization for proposed treatment, testing and/or durable medical equipment within 10 business days of the date of the appeal.
  3. Appeals of issues not related to a Decision Point Review or Pre-certification request must be sent, in writing, via certified mail, return receipt requested, through Liberty Mutual Insurance at 2501 Wilmington Road, New Castle, PA, 16105. Issues not related to a Decision Point Review of Pre-certification request include, but are not limited to, disputes as to payment amount and bill reviews (UCR disputes, re-coding of billed codes, NCCI Edit denials, etc..). **These appeals of payment amount/re-coding/UCR/NCCI Edit denials must be made within 180 days from the date of the adverse decision, signed by the treating provider, and submitted stating the issue being disputed along with a copy of the EOR (Explanation of Review) and supporting documentation. Liberty Mutual Insurance has 30 days from the date of the written appeal to respond.
  4. VOLUNTARY UTILIZATION PROGRAM - A list of CSG, Inc.'s preferred provider networks can be obtained on CSG's website at www.csg-inc.net. A request for the list of preferred provider networks can also be faxed over to CSG at 856-910-2501.

December 5, 2013

      Re: EMG/NCV Billing

EMG/NCV Billing

A PIP alert was issued approximately a year ago advising that effective January 4, 2013, medical providers must utilize the new CPT codes for NCV testing (95907-95913). There are also new EMG codes (95885 or 95886). If you are performing EMG with NCV on the same day you must utilize the new EMG codes 95885 or 95886. Use the old EMG codes 95860-95864 if you are only performing EMG without NCV. If you bill correctly you can receive almost three thousand dollars in compensation. If you want information on EMG/NCV contact the undersigned directly.

September 1, 2013

      Re: New DPRP Plan for PLIGA effective 9/1/13
PLIGA has revised their Decision Point Review Plan to include a new more onerous appeals process and new pre-certification form for surgery procedures. PLIGA now requires a pre-service appeal and post-service appeal. The new procedures are set forth as follows:
  1. PRE-SERVICE/TREATMENT/TESTING APPEAL: This is the form that NJ PLIGA says MUST be use to appeal any denials of pre-certification of proposed treatment, diagnostic testing and/or durable medical equipment. NJ PLIGA says this form and no other, must be use in the 1st level appeal otherwise they will kick the appeal back.
  2. POST SERVICE APPEAL: This is the appeal form that NJ PLIGA says MUST be used for all other appeals that do not involve denials of pre-certification for testing/treathment/durable medical equipment. Post service appeals, as stated in NJ PLIGA's latest Decision Point Review Plan, involve appeals concerning coding issues/discrepencies, bill disputes, erroneous pre-certification Penalry reductions, cross walking issues, down coding issues, etc.

PRE-SERVICE APPEAL

Pre-service appeals must be faxed to 908-382-7160 or mailed to:

New Jersey Property-Liability Insurance Guaranty Association
Attention: Appeals Department
222 Mt. Airy Road
Basking Ridge, NJ 07920
You must submit your pre-service appeal within 5 business days of the date of denial. Pre-service appeals submitted more than 5 days after the date of denial will not be considered an appeal. PLIGA considers it a new request. If you submit your pre-service appeal more than 5 days after the date of the denial wait for PLIGA to respond to your pre-service appeal (which is now a new request) and then resubmit your pre-service appeal within 5 days of PLIGA's response.

PRE-CERTIFICATION FOR SURGERIES

All requests for surgical procedures require additional information and must be submitted on the Surgery Pre-Certification Request for NJ PIP Claim Form. I have attached a copy of same.

POST SERVICE APPEAL

Post-Service Appeal forms must be faxed to 908-382-7158 or mailed to:

New Jersey Property-Liability Insurance Guaranty Association
Attention: Appeals Department
222 Mt. Airy Road
Basking Ridge, NJ 07920
All post service appeals must be submitted within 180 calendar of the adverse decision of at least 30 days prior to initiating arbitration or litigation..

FORMS

  1. Post-service appeal form
  2. Surgery pre-certification request form
  3. PLIGA's revised Decision Point Review Plan

January 2, 2013

      Re: 2013 Code Changes for Neurology

2013 Code Changes for Neurology

Please see the following memo for important code changes for Neurology and Neuro-Diagnostic Testing.

December 5, 2012

      Re: $15,000.00 Basic v. Standard Step Up Provision

Dear Medical Providers:

STANDARD POLICY

A driver/passenger who does not have automobile insurance of his own in an automobile covered by a standard policy of insurance where the insured (not the injured person) elects less than $250,000.00 of PIP coverage, the injured person is entitled to $250,000.00 of PIP coverage. Example if the patient is not a resident relative of the named insured and the policy only provides $15,000.00 of PIP coverage the passenger is entitled t0 $250,000.00 of PIP. N.J.S.A. 39: 6A - 4.3 (f) states:
"an option elected by the named insured in accordance with this section shall only apply to the named insured and any resident relative in the named insured's household who is not a named insured under another policy."

BASIC POLICY

A driver/passenger who does not have automobile insurance of his own who is in an automobile covered by a basic policy of insurance is only entitled to $15,000.00 of personal injury protection coverage even though he did not elect same. N.J.S.A. 39: 6A - 3.1 (a) states:
that the $15,000 election applies to persons sustaining bodily injury while occupying entering or alienating from an automobile.
It is absolutely critical that you obtain a copy of the declaration page and or policy of insurance. I will help you determine if the insured is covered under a standard automobile policy or a basic policy of insurance.

November 7, 2012

      Re: New PIP Fee Schedule

Dear Medical Providers:

New PIP regulations Effective January 2013

The new PIP regulations become effective approximately January 3, 2013. The new regulations affect all medical providers but the substantial changes are to surgical centers, pain management physicians, surgeons, VNG testing, and acupuncturists. (New appeal Process goes into effect January 3, 2014)

New PIP Regulations

October 24, 2012

      Re: New PIP Regulations have been adopted Dear Medical Providers:
The Department of Banking and Insurance adopted the new regulations without a single concession to the medical providers. (New regulations )

Coalition Meeting

DATE: November 6,2012
TIME: 6:30pm
PLACE: Fornos of Spain (47 Ferry St, Newark, NJ 07105)

The new regulations mean the following:
  1. Discography and other procedures are not permitted at surgical centers
  2. Pain Management Care Paths
  3. Further reduction in New Jersey fee schedule amounts
  4. Chiropractic and acupuncture treatment cannot be performed on the same day
  5. Platelet rich plasma (PRP) injections are only reimbursable for chronically injured tendons.
  6. Numerous other issues
Join the coalition. Ross Pearlson, Esq. from Wolff Samson is prepared to file a lawsuit to overturn the new regulations.
Ross Pearlson's contact information is: rpearlson@wolffsamson.com (973) 530-2100.

September 18, 2012

      Re: New Appeals Process for NJM Dear Medical Providers:

NJPLIGA's new DPR/Precertification Plan (DPRP) became effective on August 15, 2012.

Along with this new DPRP, administration of the DPRP transferred from Procura to NJPLIGA. Accordingly, effective August 15, 2012, all requests for DPR / Pre-certification and Appeals should be sent directly to NJPLIGA.

For DPR/Precertications:

All requests should be faxed to:
NJPLIGA
Attention: Precertification Department
(908) 382-7157

or mailed to:
NJPLIGA
Attention: Precertification Department
222 Mt. Airy Road
Basking Ridge, NJ 07920

or e-mailed to:
Precert@NJGuaranty.org

For Appeals:

All requests should be faxed to:
NJPLIGA
Attention: Appeals Department
(908) 382-7158

or mailed to:
NJPLIGA
Attention: Appeals Department
222 Mt. Airy Road
Basking Ridge, NJ 07920

or e-mailed to:
Appeals@NJGuaranty.org

Notable changes in NJPLIGA DPRP are as follow:

Second Level Appeal
If a First Level Appeal is denied, you must file a Second Level Appeal at least thirty (30) days prior to filing a Demand for Arbitration and retain Proof of receipt of the Second Level Appeal request.

The appeal should set forth the basis for the Second Level Appeal and the facts underlying the dispute. Copies of all relevant supporting documents, including, but not limited to, any unpaid medical bills for medical expenses that may be in dispute must be included.

Second Level Appeals must be submitted in writing to NJPLIGA by facsimile at (908)382-7158

Or by mail to:

New Jersey Property-Liability Insurance Guaranty Association
Attention: Appeals Department
222 Mt. Airy Road
Basking Ridge, NJ 07920

Authorized testing, treatment and/or DME is only approved for the range of dates noted in the determination letter(s).
Therefore, if treatment is approved and is not completed within fourteen (14) calendar days from the date in which the authorization period expired, a written extension request, including the supporting reason for the extension, must be sent to NJPLIGA.

The request can be faxed to (908)382-7157

Or mailed to the following address:

New Jersey Property-Liability Insurance Guaranty Association
Attention: Appeals Department
222 Mt. Airy Road
Basking Ridge, NJ 07920


July 9, 2012

      Re: New Appeals Process for NJM

Dear Medical Providers:

New Jersey Manufacturers' has revised their Decision Point Review Plan to include a new more onerous appeals process. New Jersey Manufacturers now requires a pre-service appeal and post-service appeal.

Pre-service appeals must be sent to the PIP claims representative. This is the person referenced on the explanation of benefits to his or her fax number (All post-service appeals are to be sent to 609-963-6075, pre-service appeals are sent to the fax number for the PIP claim adjuster). You must submit your pre-service appeal within 30 days of the date of denial. Pre-service appeals submitted more than 30 days after the date of denial will not be considered an appeal. New Jersey Manufacturers considers it a new request. If you submit your pre-service appeal more than 30 days after the date of the denial wait for New Jersey Manufacturers to respond to your pre-service appeal (which is now a new request) and then resubmit your pre-service appeal within 30 days of New Jersey Manufacturers??? response.

If you want to reduce the amount of paperwork complete New Jersey Manufacturers??? post-service appeal, make 2 copies, cross out the words post-service on one of the copies and use that appeal form for your pre-service appeal. Make sure you send the pre-service appeal to the PIP claims adjuster. When New Jersey Manufacturers denies your pre-service appeal you then can use the other post-service appeal form and send to New Jersey Manufacturers. This firm will make sure that the post-service appeal has been completed and sent correctly.

Also important pre-certification for surgeries now require submission on a surgery precertification request form.

New NJM forms:

  1. Post-service appeal form
  2. Surgery pre-certification request form
  3. New Jersey Manufacturers revised Decision Point Review Plan

April 30, 2012

      Re: Discography - CPT codes 62290, 62291 and 62292

Dear Surgical Centers:

Two good arbitration awards for discography compensation for surgical centers. As you know there is no ASC group rate for CPT codes 62290, 62291 and 62292. This firm was successful in obtaining additional arbitration awards where the DRP agreed that discography was more similar to a percutaneous decompression and awarded the surgical center a Group 9 rate as opposed to a Group 1 and a Group 5 rate as opposed to a Group 1. We now have arbitration awards awarding a surgical center a Group 9 and Group 5 rates. As you are aware Group 1 allows $1265.10, Group 5 allows $2723.94 and Group 9 allows for $5,086.97. Even at a Group 5 you would receive more than double the amount of compensation.

April 17, 2012

      COALITION MEETING

PLACE: Wolff & Samson
One Boland Drive, 2nd Floor
West Orange, NJ 07052
DATE: Tuesday, April 17, 2012
TIME: 6:30pm
RSVP:
Ross Pealson, Esq.
rpearlson@wolffsamson.com
(973) 530-2100
Joe Massood, Esq.
jmassood@massoodlaw.com
(973) 696-1900

CHIROPRACTORS/ACUPUNCTURISTS

The Coalition is willing to oppose the proposed regulations which seek to include acupuncture procedures within the daily maximumcap thereby prohibiting reimbursement for chiropractic and acupuncture procedures performed on the same day. The justification offered by the Department of Banking Insurance is that the procedures performed by acupuncturists and chiropractors are similar. The Coalition will need to submit proof that the procedures performed by acupuncturists and chiropractors are distinct and separate.
The Coalition will undertake this task only if chiropractors and acupuncturists are willing to join and contribute to the Coalition. To date I contributed over 30 hours of legal time free of charge to the Coalition. These regulations affect our livelihood. If you want the Coalition to oppose these regulations please send a retainer check in the amount of $2,000.00 to Ross Pearlson at Wolff Samson. Please attend the meeting.

April 3, 2012

      Re: Coaliton for Quality Healthcare

Dear Members of the New Jersey Coalition for Quality Health Care and Medical Providers:

Please review this memorandum and chart prepared by Ross Pearlson and myself. The proposed regulations can be defeated. In order to accomplish this task the Coalition needs additional data as requested and more members to fund the Coalition.
If you have not joined the Coalition please do so. Please send a retainer check in the amount of $2,000.00 to Ross Pearlson, Esq. at Wolff & Sampson, One Boland Drive West Orange, NJ 07052.

March 14, 2012

      Re: CPT code 63030

Dear Spine Specialists:

Further research has demonstrated that the Medicare RVU explanations do permit co-surgeons for CPT Code 63030 but they have to be two different specialties. A pain management specialist and orthopaedic surgeon are permitted to bill as co-surgeons. For more information, please see this page indicating that co-surgeons are permitted and the National Physician Fee Relative Value Calendar

March 12, 2012

      Re: Plasma Injections

Dear Providers:

In the PIP alert sent out earlier today I indicated that an ambulatory care facility may bill platelet rich plasma injection (CPT code 86999), autologous harvesting (CPT code 38206) and therapeutic apheresis platelets (CPT code 36513). It has been brought to my attention that the CMS requires ambulatory care facilities to use 0232T codes. I am researching this issue.

March 9, 2012

      Re: Maximizing recovery, current regulations

Dear Providers:

There are number of medical procedures and coding regulations which permit a surgical center to legally and ethically maximize recovery. There is no consensus among the Dispute Resolution Professionals on the topics listed below. If the correct legal arguments are made before the right Dispute Resolution Professional you can prevail.

PLASMA INJECTIONS

Maximum recovery $10,100.00. An ambulatory care facility may platelet rich plasma injection bill (CPT code 86999), autologous harvesting (CPT code 38206) and therapeutic apheresis platelets (CPT code 36513). Only a physician is required to bill CPT code 0232T for plasma injections. The AMA guidelines specifically state that when a physician performs a plasma injection they are required to utilize CPT code 0232T which is included in the operative procedure. The same is not true for surgical center. The Honorable Thomas LaConte, J.S.C vacated an arbitration award entered by DRP Kaczka who only permitted reimbursement for the surgical center for CPT code 86999. The Honorable Thomas LaConte, J.S.C. allowed for reimbursement for all 3 CPT procedures. CPT codes 86999, 38206, and 36513 do not have a ASC group rate. If the surgical center bills a group 9 for all three procedures the maximum recovery is approximately $10,100. The first procedure billed at the Group 9 rate of $5,086.00 the second and third procedures billed at $2,543.00 each (50% of Group 9 rate) pursuant to the multiple modality rule.

MULTIPLE MODALITY RULE

Not all procedures performed a surgical center are subject to the multiple modality rule. Medicare has provided a list of procedures that are not subject to the multiple modality rule. If you want a comprehensive list of procedures that are not subject to the multiple modality rule performed at surgical centers visit our website at www.massoodlaw.com or click on ASC which will link you to Medicare's website. This does not mean that all Dispute Resolution Professionals will follow this list. Despite the fact that the NCCI edits clearly exempt certain procedures from the multiple modality rule, there are still a number of Dispute Resolution Professionals that automatically subject all procedures performed at an ASC to the multiple modality rule. Example: Arbitrators have found that CPT codes 62290, 62291, 62292 (injection for discography) are not subject to the multiple modality rule based upon the NCCI edits which specifically exempt same. Once again you can visit our website to obtain a list of procedures that are not subject to the multiple modality rule performed at surgical centers.

BILATERAL PROCEDURE

Procedures performed at surgical centers are not subject to the bilateral procedure, N.J.A.C. 11:3-29.4. Most DRPs agree with the first procedure paid at 100%, all other procedures after are paid at 50% except those exempt by the NCCI edits which should be paid at 100%.

FACET JOINT INJECTIONS

Effective January 1, 2010 the following CPT codes were deleted: 64470, 64472, 64475 and 64476. Effective January 1, 2010 the following CPT codes were added: 64490, 64491, 64492, 64493, 64494 and 64495. The new facet joint injection codes do not have an ASC group rate. The 'old' facet joint injection codes had a group 1 ASC rate. Some DRP's have agreed with us that the new facet joint injection codes are payable at a higher ASC rate than group 1. Some DRP's have allowed a group 9 some have allowed an ASC rate of group 2 or 3. The strongest argument is that under the 'old' CPT codes the surgical center was entitled to reimbursement for the fluoroscopic guidance and the facet joint injections. The new facet joint injection CPT codes now include in the definition fluoroscopic guidance. Therefore it would be inappropriate to carry over a Group 1 ASC rate. A higher ASC rate is necessary to fairly compensate the surgical center for performing fluoroscopic and facet joint injections under one CPT code. Most DRP's still reject this argument and award only a group 1. You should bill more than a Group 1 ASC rate for 64490, 64491, 64492, 64493, 64494 and 64495.

DISCOGRAPHY

There is no ASC group rate for CPT codes 62290, 62291 and 62292. Surgical Centers can bill same at the group 9 rate. We have been successful in some instances in arguing that discography (CPT code 62290) is synonymous with a percutaneous decompression procedure (CPT code 62287) which carries a group 9 ASC rate. However, most DRPs still reject this argument and only allow for a group 1.

SPINAL WAND AND OTHER DEVICES

We have been successful in receiving compensation for the spinal wand needed to perform the discography@20% over invoice or $1,920.00, N.J.A.C. 11:3 - 29.4 (p).

ALL MEDICAL PROVIDERS

Ross Pearlson, Esq. of Wolff Sampson and I will shortly issue a comprehensive bulletin on the New Proposed Regulations. The Department of Banking and Insurance reneged on its promises. All of the current cervical and lumbar discectomy procedures are still on the fee schedule for orthopedic surgeons. These procedures will no longer be able to be performed at a surgical center. Discography will no longer be able to be performed at a surgical center. We are in the process of providing a comprehensive overview of the regulations.

February 22, 2012

      Re: CPT code 63056 v. 63030

Dear Providers:

The Medicare RVU explanations permit a co-surgeon for CPT Code 63056 but only allow an assistant surgeon for CPT Code 63030. Additionally, the Medicare regulations actually state you need supporting documentation to establish the necessity of a co-surgeon. I would suggest adding one or two lines to the operative report stating that this is a delicate operative procedure which can cause paralysis and requires two sets of hands. Additionally, when using CPT Code 63056, the NCCI edits and the RVU allow for a co-surgeon for an annuloplasty, 22526 and 22527, and also state that the annuloplasty, CPT Codes 22526 and 22527, is not included in CPT Code 63056. more information

December 1, 2011

      Re: CPT codes 62290 and 62291

Dear Surgical Centers:

Please bill CPT codes 62290 and 62291 at the Group 9 rate. We have been successful in convincing some Arbitrators that you are entitled to a Group 9 rate.

October 19, 2011

      Re: Revised First and Second Appeal Letters for Treating and Non-Treating Physicians

Dear Medical Provider:

Please find revised first level and second level appeal forms for treating and non-treating physicians. The appeals have been revised so you can identify issues which prevent the insurance carriers from stating that your appeal is generic. When the new regulations go into effect, the Department of Banking and Insurance is supposed to provide a form appeal letter that all providers must use. It is my understanding that the form appeal letter will require the medical provider to identify issues.

APPEAL LETTERS

  Treating Non-Treating
Level 1
Level 2

August 1, 2011

      Re: Proposed Regulations

Dear Medical Provider:

The Department of Banking and Insurance has made comprehensive new regulations. If you would like a copy of same please go to massoodlaw.com and click on proposed regulations.

1. APPEALS

New Regulations will prohibit a medical provider from relying upon the patients to submit a claim on their behalf. The appeals process must be meticulously adhered to. Even without the new regulation DRPs are no longer accepting generic appeals. You must provide a specific basis to support the medical necessity in your appeal and/or your response to the insurance carrier's inquiry if one is presented. File your appeals timely. Make sure the appeal is sent to the correct entity and the correct fax number and/or address. Make sure you file a second level appeal for the carriers that require same. Make sure the second level appeal is filed with the correct entity, usually the insurance carrier. Here are the revised appeal letters, please use them:

APPEAL LETTERS

  Treating Non-Treating
Level 1
Level 2

NEW APPEALS PROCESS

TREATMENT APPEAL and ADMINISTRATIVE APPEAL

A. TREATMENT APPEAL

Treatment appeal must be filed within five (5) days from the date of the pre-certification request when treatment is denied. If the provider missed the five (5) day deadline the provider can submit a second pre-certification request for treatment and if the pre-certification request for treatment is denied the provider must file an appeal within five (5) days from the date of the denial.

B. INSURANCE RESPONSE

The insurance carrier must respond within 10 days from receipt of the treatment appeal.

C. ADMINISTRATIVE APPEAL

All other types of denials must be administratively appealed. Administrative appeal must be filed within 180 days from the date of the denial.

D. INSURACE RESPONSE

The insurance carrier has 30 days in which to respond to the appeal.

E. DESIGNATED FAX NUMBER

The insurance carrier must provide a fax number, mailing address of email address where the internal appeals must be sent. The provider must proof of receipt.

F. DEMAND FOR ARBITRATION

Demand for arbitration must be accompanied by the internal appeal decision or certification that an appeal was made and/or decision was received by the insurance carrier.

OTHER IMPORTANT CHANGES

  1. Daily cap was raised to $105.00 from the current $99.00. However, everything is now included.
  2. Kinesio taping is included in the $105.00 daily cap.
  3. Platelet riched plasma (PRP) injections are only reimbursable for treatment of chronically injured tendons.
  4. TENS and EMS including batteries, leads, pads and other accessories in included in the purchase price of the TENS or EMS unit.
  5. The surgical center is not entitled to reimbursement for CPT codes that do not have an amount on the physician's fee schedule.
  6. Arthroscopic knee surgery (CPT code G0289) is an add on code which may be reported only once per extra compartment. CPT codes 29874 and 29877 are not permitted with other arthroscopic procedures.
  7. MUA of the spine (CPT code 22505) may only be billed once, not for three (3) separate levels.
  8. Acupuncture is included in the daily cap (CPT codes 97810, 97811, 97813, 97814)
  9. Daily cap also includes CPT codes 97039, 97139

July 14, 2011

      Re: Revised Assignment of Benefits

Dear Medical Provider:

Based upon recent developments, once again I am required to revise the Assignment of Benefits. Please use same immediately. This Assignment specifically advises the patient that you will accept the amount awarded and/or settled for and will not seek additional payment. This language is important because it provides consideration for the patient to sign the Assignment. It will also alleviate a number of notice provisions.

July 14, 2011

      Re: Lumbar Procedures/Surgical Centers

ATTN: Surgical Centers/Orthopaedic Surgeons

The proposed regulations prohibit lumbar surgeries from being performed at an outpatient facility (surgical centers). I have spoken with Mark Manigan, Esq. from Brach Eichler, LLC. He has informed me that his firm will be filing a suit on behalf of the surgical centers to prevent same.

June 6, 2011

      Re: Separate Reimbursement/-59 Modifier

Dear Medical Provider:

The National Correct Coding Institute (NCCI) prohibits reimbursement unless a 59 modifier has been appended to a CPT code when more than one CPT code is billed on the same date. Even if the NCCI permits separate reimbursement for multiple procedures done on the same date, the medical provider is prohibited from receiving payment if the CPT was not billed with a 59 modifier.

Examples

Chiropractic/PT
The NCCI edits permit reporting of CPT code 98941 and 97124 (massage) when performed at the same time but only if the medical provider has annexed a 59 modifier. Even though both codes are within the cap, the insurance carrier can deny reimbursement for CPT 97124 pursuant to the NCCI edits if it was not billed with a 59 modifier.

Orthopedic Surgery
The NCCI edits permit reporting of CPT code 29826 and 29822 (debridement) when performed at the same time but only if the medical provider has annexed a 59 modifier. Even though both codes are separate procedures, the insurance carrier can deny reimbursement for CPT 29822 pursuant to the NCCI edits if it was not billed with a 59 modifier.

NCCI Overview

Our office is well versed with the NCCI edits. A brief summary of the NCCI edit procedure is as follows:
  • The primary procedure appears in column 1.
  • CPT codes that are not to be reported, and therefore not compensable, when billing the primary procedure will appear in column 2.
  • Additionally, the column to the far right will indicate whether a modifier is allowed.
    • 0 - prohibits use of a -59 modifier
    • 1 - permits use of the -59 modifier
    • 9 - means not applicable.

Accordingly, the correct method is to check the NCCI edits to see if a modifier 59 is permitted (this will be designated by the number 1). When permitted, and if special circumstances are applicable, you must annex a 59 modifier to the column 2 code in order for it to be properly reported and therefore compensable.

Please contact me to discuss same.


June 2, 2011

      Re: Assignment of Benefits/Appeals

Dear Medical Provider:

I have revised the Assignment of Benefits. Please utilize it immediately. The revised assignment includes language which allows same to be revoked if both the doctor and patient mutually agree. The assignment cannot be revoked unilaterally. This language is important because if you forget to file an appeal the assignment allows you to include the patient for arbitration. Patients do not have to file an appeal. The old assignment included the word "irrevocable." The Insurance carrier would argue that the patient could not be added to the arbitration because the patient issued an irrevocable agreement. Some of the DRP's have agreed with this argument. Now if the insurance carrier questions your appeal, this assignment will allow the patient to make a claim directly on your behalf for payment. I have also deleted paragraphs 7, 8 & 9 off the old Assignment of Benefits.

May 5, 2011

      Re: PIP Memo

Dear Medical Provider:

APPEALS

Be advised that effective 3/28/11, Procura Management, Inc. is administering Allstate Insurance Company's NJ Decision Point Review and Pre- Certification program. In addition, some changes have been made to the Procura Decision Point Review Plan.

NCCI EDITS

The new regulations permit the insurance carrier to access the NCCI edits to determine if a code can be billed separately. Even if the NCCI edits permit separate billing you have to annex the appropriate modifier.

If you are interested in receiving this information or discussing same, please contact Joseph A. Massood directly at 973-696-1900.

February 23, 2011

      Re: Arbitration Summary

Dear Medical Provider:

The National Arbitration Forum (NAF) has adopted new rules which require the medical provider to submit an arbitration summary. The NAF arbitration summary is using the CPT Worksheet that our firm developed and has been using for over three (3) years. Unlike other firms, as part of our client services, this firm prepares the CPT Worksheet, now called the arbitration summary, on your behalf. By using our firm to file your PIP arbitrations, under the new NAF rules, you are not required to perform additional work.

February 3, 2011

      Re: Surgery Centers - 30% Out of Network Penalty

Dear Medical Provider:

Effective July 10, 2010 the Department of Banking and Insurance amended N.J.A.C. 11:3-4.8(b)6 which allows insurance carriers to create a network for surgical centers. If the insured elects to receive treatment at an out of network surgical center the insured is subject to a 30% co-payment penalty.

Insurance carriers are now notifying their insured's that they have developed a network for surgical centers. The insurance carriers are required to notify the treating physician and patient of their network system. I suggest that you contact the treating physician and patient, if possible and ask if they received notice from the insurance carrier regarding the out of network penalty. If the patient and the treating physician did not receive notice, the insurance carrier is not permitted to impose the 30% penalty. I also suggest that you check your EOBs for any reference to a 30% penalty.

January 21, 2011

      Re: Internal Appeals - Carrier Requirements

Dear Medical Provider:

We have conducted a comprehensive review of the Decision Point Review Plans for most of the major auto insurance carriers and condensed the information into an easy to read Excel spreadsheet.

The document is proprietary to Massood and Bronsnick, LLP. And any unauthorized reproduction, dissemination or use of the document is strictly prohibited without the express written permission of its owner.

If you are interested in receiving this information or discussing its contents, please contact Joseph A. Massood directly at 973-696-1900.

December 15, 2010

      Re: 2nd Level Appeal, SOME GOOD NEWS

Dear Medical Provider:

The Department of Banking and Insurance will be implementing a uniform appeals process. This uniform appeals process should be implemented within the next two (2) months. A second level appeal will be required, but can be sent by fax (not certified mail).

Robert Capuzzo, Esq. of Chasan, Leyner & Lamparello, chief counsel for Allstate, has informed me that Allstate will issue a bulletin within the next week eliminating the certified mail requirement for the second level appeal. It is also my understanding that Allstate's third party administrator, Procura, will eliminate the certified mail requirement for all of their carriers including but not limited to, Progressive, Esurance, Clarendon and PLIGA. However, I recommend that you continue to send the second level appeal by certified mail until we receive this guarantee in writing. This firm will seek to have the insurance carrier reimburse you for the cost of the certified mail.

Additionally, Robert Capuzzo, Esq. has also advised that there will be significant changes to Allstate's Decision Point Review Plan in the next month. We will update you as more information becomes available.

December 9, 2010

      Re: USAA Assignment Of Benefit

Dear Medical Provider:
      USAA is demanding that the medical providers utilize their assignment of benefits. If you are a non-treating physician this may be difficult to comply with because the patient may visit your facility on one occasion and getting the patient to sign same can be difficult. For your convenience a copy of the USAA Assignment of Benefits is attached hereto.       The patient will sign your assignment of benefits. If you have the ability, have the patient sign the USAA assignment of benefits as well. If the patient does not sign the USAA assignment, I recommend that your office execute the USAA Assignment of Benefits and submit it along with the assignment of benefits signed by the patient and the following letter:

Attn: Adjuster
USAA General Indemnity Company
9800 Fredericksburg Road
San Antonio, Texas, 78288

	Re:	Patient's name:
		Patient's policy number
		DOL
		Assignment

Dear Sir/Madam:

On behalf of the medical provider I have executed
the assignment of benefits as requested.  We agreed to the
terms and conditions.  The USAA assignment of benefits 
places no conditions or requirements on the patient.  We
have already provided USAA with an assignment of benefits 
that has been executed by the patient which is very similar
to USAA's assignment of benefits.  If we do not receive a 
written objection within seven (7) days from the date of 
this letter, it shall be expressly understood that USAA 
has accepted these assignments.

Very Truly Yours, 

By:_____________________
	 MEDICAL PROVIDER 
                    

November 29, 2010

      Re: Two Level Appeal Process

Dear Medical Provider:
      The Department of Banking and Insurance approved a two-level appeal process. Unfortunately, there is no uniform appeal process. The timeframes and requirements vary by insurance carrier. For example, Allstate's vendor is Procura. Their first level appeal letter must be sent by fax to Procura and the second level appeal letter must be sent by certified mail to Allstate.
      In an attempt to meet the requirements for all carriers for the first level appeal and second level appeal I am providing you with generic appeal letters. Please note that it is incumbent upon you to read each carrier's decision point review plan to make sure that these appeal letters comply with each carrier specific requirements. I recommend that you do the following:

FIRST LEVEL APPEAL

  1. First level appeal letter should be filed within 10 days from the date of the denial. The timeframe differs from carrier to carrier. However, the shortest timeframe is 10 days. If you file your appeal within 10 days you are covered. The appeal must be for any type of denial including medical necessity, underpayment and/or coding.
  2. The first level appeal is sent to the vendor. The appeal should be sent by fax.
  3. The appeal must be signed by the provider.
  4. If the denial is for medical necessity you must provide the progress notes and/or treatment records to the vendor with the appeal.
  5. See the first level appeal forms for treating physicians and non-treating providers.

SECOND LEVEL APPEAL

  1. Second level appeal may be required. The second level appeals are usually sent to the insurance carrier as opposed to the vendor. The second level appeal must include all relevant supporting documentation including progress notes, medical reports and the basis for your appeal.
  2. The second level appeal is to be sent certified mail return receipt requested.
  3. The appeal must be signed by the provider.
  4. See the second level appeal forms for treating physicians and non-treating providers.

FAILURE TO APPEAL
HOW TO WIN

Failure to appeal or provide a proper appeal should not result in a dismissal of your claim if you utilize the assignment of benefits I prepared. The assignment allows you to include the patient's name in the arbitration which will prevent the insurance carrier from dismissing your case on the basis that you failed to file an appeal. Please be advised that filing an appeal is still the best practice for numerous reasons, three of which are mentioned below:
  1. Filing arbitration on behalf of the medical provider and the patient can still result in the claim being dismissed under the entire controversy doctrine. If more than one medical provider adds the patient's name to their arbitration, then the patient has an obligation to bring all claims under one arbitration which could result in your case being dismissed.
  2. Your appeal strengthens your case. Remember the appeal letters that I prepared request the insurance carrier to provide you with a specific medical basis for denying the patient's medical treatment and a copy of their report. Usually the insurance carrier does not comply with this request.
  3. Filing an arbitration on behalf of the medical provider and the patient can create a conflict precluding the medical provider from collecting from the patient.

November 12, 2010

      Re: Dismissal of Your Medical Claim/Internal Appeal

Dear Medical Provider:
      The Commissioner of the Department of Banking and Insurance issued a Bulletin on October 30, 2010 directing Arbitrators to dismiss claims if the medical provider does not comply with all aspects of the insurance carrier's internal appeal (copy of bulletin enclosed). If the internal appeal process requires you to appeal within 10 days and you fail to do so, our Commissioner believes the appropriate remedy is to deny the medical provider's claim in its entirety simply because the medical provider did not appeal within the timeframe. According to our Commissioner, the medical provider cannot remedy that defect and the claim should be dismissed. My belief is that the Arbitrators will succumb to the pressure placed upon them by the Department of Banking and Insurance and begin to deny claims because the internal appeal process was not complied with.
      Additionally, generic appeal letters may also be deficient. Example: If the insurance carrier requests the medical provider to provide specific information in their appeal and the medical provider fails to do so, the claim could be dismissed. It my opinion, the Commissioner's directive instructing Arbitrator's on how to rule is improper and violates the separation of powers. This will need to be challenged in Court.
      In the meantime, it is necessary for the medical providers to comply with each insurance company's appeals process.

Dept of Banking and Insurance Bulletin

             Very Truly Yours,

             JOSEPH A. MASSOOD, ESQ.


October 20, 2010

      Re: PIP Alert
          Kinesio Taping

Dear Provider:
      Unfortunately I must bring to your attention that the American Chiropractic Associates (ACA) issued a coding clarification with regard to kinesio taping. According to the ACA, kinesio taping (CPT codes 29200-29280 and 29520-29590) is not supported beyond the initial service, or where restorative treatment was provided, or where the purpose was not to "stabilize" but was instead therapeutic. According to the ACA when applying kinesio tape to a patient in conjunction with another therapy the kinesio taping should not be separately reported.
      I urge all chiropractors to contact the ACA and ask for a further clarification or reconsideration. I am attaching a copy of the ACA coding clarification statement.

             Very Truly Yours,

             JOSEPH A. MASSOOD, ESQ.


October 7, 2010

      Re: PIP Alert
          Plasma Injections

Dear Medical Provider:
      Effective July 1, 2010, CPT code 86999 (plasma transfer/medicine procedure) has been deleted and providers are instructed to use category III CPT code 0232T when performing platelet rich plasma injections. Unfortunately the CPT now states CPT code 0232T is not to be reported in conjunction with the following CPT codes:

  • 20550 (Injection single tendon or ligament)
  • 20551 (single tendon insertion)
  • 20926 (tissue graft)
  • 76942 (ultrasound guidance for needle placement)
  • 77002 (fluoroscopic guidance for needle placement)
  • 77012 (computed tomography guidance for needle placement)
  • 77021 (magnetic resonance guidance for needle placement)
  • 86965 (pooling of platelets or other blood products)

These codes are now considered included.

SURGICENTERS ONLY
      The insurance carriers are arguing that surgicenters are not entitled to separate reimbursement for plasma injections pursuant to N.J.A.C. 11:3-29.4 (o) 6. This provision of the Administrative Code states that the ASC facility fee shall include blood plasma, platelets, etc. However, we are arguing that the regulation does not include plasma transfer because this requires the medical provider to collect plasma/blood from the patient and then re-inject it back into the patient. The regulation that the insurance carrier is relying upon is for blood or plasma being administered during the operation. To the best of my knowledge there have not been any arbitration awards on this issue. We are confident that we will prevail. However, if the insurance carrier???s do prevail on this issue, it may be necessary to perform the plasma injections on a separate date. We will keep you informed.

      New Regulations do not appear in the 2010 CPT Manual. The New Regulations can be found at http://www.ama-assn.org/ama1/pub/upload/mm/362/cptcat3codes.pdf.

             Very Truly Yours,

             JOSEPH A. MASSOOD, ESQ.


September 15, 2010

      Re: Clarification for PIP Alert of MUAs
          Cervical,Thoracic and lumbar may be billed separately

Dear provider and/or billing facility:
      When billing for the MUAs use CPT code 22505 and list each individual region (cervical, lumbar and thoracic) charging as one lump sum (your charge for each x 3) indicating three units as follows:

CPT Code Units Charge
MUA Physician
22505 3 $592.71 (3 @ $197.57-fee schedule North)
Surgicenter
22505 3 $5,083.17 (3 @ $1,694.39-fee schedule North)

September 11, 2010

      Re: PIP Alert
          MUA
          Cervical,Thoracic and lumbar may be billed separately

Dear provider and/or billing facility:
      When performing cervical, thoracic and lumbar MUAs bill each separately under CPT code 22505. I have been successful in receiving the full amount per fee schedule for the cervical, thoracic and lumbar MUAs performed on the spine. The surgical center should also bill each separately so they may collect payment for each MUA performed.


March 4, 2010

      Re: PIP Alert
          Pain Management CPT Revisions

Dear Medical Provider:
      Effective January 1st 2010, there have been several changes in regard to CPT coding most notably in Pain Management.

      Facet Joint Injections CPT code 64470-64476 have been deleted and replaced with CPT code 64490-64495. Under the new CPT regulations CPT code 64491, 64492, 64494 and 64495 have been designated as add- on codes for injections performed on the second and third levels and therefore, are payable at 100%. However, Fluoroscopic Guidance CPT code 77003 is included in CPT code 64490 through 64495 and therefore is not permitted to be billed separately. Providers may still continue to bill and get reimbursement for Fluoroscopic Guidance CPT code 77003 when performing CPT codes 64622 through 64627. Please see the enclosed CPT changes.

      If you have any questions, as always please do not hesitate to contact me.


January 27, 2010

      Re: PIP Alert
          Kinesio Taping
          Lumbar Strapping

Dear Providers:
      Please note that CPT Code 29220, lumbar strapping has been deleted. The new CPT Code is 29799 for lumbar strapping which does not appear on the physician's fee schedule. You may charge your usual and customary rate.


January 25, 2010

      Re: PIP Alert
          Chiropractors
          Adjustment, Massage, Therapeutic Activities

Dear Chiropractor:
      It has been brought to my attention that Liberty Mutual and other insurance carriers are now denying payment for massage, CPT Code 97124, neuromuscular reeducation, CPT Code 97112 and manual therapy technique, CPT Code 97140 as included in chiropractic manipulation CPT Code 98941-98942. The insurance carrier is issuing payment less than the $99.00 per cap. The new regulations state that a chiropractor is prohibited from billing CPT Code 97112, 97124 and 97140 if they perform these services on the same region that the chiropractor manipulated. In order to receive $99.00 per day cap payment if you adjust the cervical, thoracic and lumbar spine and you perform massage on the shoulder (which you are now permitted to do) you may receive payment for both the chiropractic manipulation and the massage by annexing a 59 modifier. The shoulder is not the same region; therefore you are entitled to payment.


January 20, 2010

      Re: Health Care Claims
          Revised Assignment of Benefits
          New Law

Dear Medical Provider:
      The Legislature enacted law which requires the health insurance carriers to issue payment directly to the medical provider. The new legislation will prevent the insurance carriers from sending payment directly to the patient. It is imperative that your Assignment of Benefits contain language directing the health care carrier to issue payment directly to you. Make sure the following language is included in your Assignment of Benefits for Health Insurance Claims:

      I, the patient, do hereby direct the health insurance carrier to issue payment on my behalf directly to the medical provider.


January 13, 2010

      Re: PIP Alert - New Assignment of Benefits Posted

Dear Provider:
    The revised Assignment of Benefits allows this firm to include the patient's name on the arbitration demand if the insurance carrier seeks to dismiss the arbitration because the medical provider failed to appeal. The patient is permitting you to include his or her name on the arbitration demand. At the present time, we are contacting the patient directly (if you failed to file an appeal) to obtain their permission to do same. The new Assignment will alleviate that problem. Placing the patient's name on the arbitration demand could create a conflict between the medical provider and the patient. Accordingly, this firm will only include the patient's name on the arbitration demand if the insurance carrier challenges your appeal.

  1. New Assignment of Benefits

September 28, 2009

      Re: PIP Alert - Ammended Fee Schedule

The Appellate Division has issued an ammended fee schedule

See the DOBI Web site for more information

  1. Amended Fee Schedle (20090928)

August 10, 2009

      Re: PIP Alert - New Fee Schedule Passed

The Appellate Division passed the new fee schedule for medical services rendered on or after August 10, 2009.

N.J.A.C. 11:3-29.1 et seq;

  1. Physician's Fee Schedule (31) Pages;
  2. Dental Fee Schedule (2) Pages;
  3. Home Care Services;
  4. Ambulance Services Fee Schedule;
  5. Fee Schedule for Durable Medical Equipment, Prosthetics, Orthotics, & Supplies;
  6. CPT Codes subject to Daily Maximum;
  7. Ambulatory Surgical Center Facility Fee Schedule.

May 29, 2009

      Re: PIP Alert-UCR

Dear Provider:

    The NAF Arbitrator's recently held a meeting concerning UCR. I have been advised by several DRPs that if the medical provider bills different amounts for the same CPT Code in the same time frame, the medical provider will now be awarded the lowest amount billed even if they have EOBs to establish payment for higher amounts. Example: The insurance carrier provides a billing history which demonstrates that the medical provider charged the sum of $3,000.00, $3,500.00, $4,000.00 and $4,500.00 for CPT Code 62311 in 2007. Even if the medical provider has EOBs showing payment in the amount of $4,500.00, the medical provider is now going to receive the lowest amount billed. The medical provider is not precluded from raising his fee but must do so in a reasonable manner. Example: The medical provider charges $3,000.00 in 2007 and in 2008 charges $3,300.00 (10% is a reasonable increase).


May 5, 2009

      Re: PLIGA is not required to pay medical bills for an uninsured person injuries in a vehicle insured with a dollar-a-day policy

Dear Provider:

      The NJ Supreme Court in Sanders v. Langemeier et. Al., A-4335-06T3 held that a passenger who does not have automobile insurance of his own who is injured in a vehicle covered under a dollar-a-policy is not entitled to collect payment from PLIGA for non-emergent medical treatment. The Supreme Court reversed the Appellate Division. In light of the NJ Supreme Court Decision Medical providers must verify that the patient has automobile insurance of their own and if that patient does not have insurance of his own that the patient is a resident relative of someone who possesses a standard PIP policy or the patient is in a vehicle that is covered under a standard PIP policy. If the patient is uninsured and an occupant of dollar-a-day vehicle the medical provider can no longer collect payment from PLIGA.

             Very Truly Yours,

             JOSEPH A. MASSOOD, ESQ.

Massood & Bronsnick, LLC
Wayne Office
50 Packanack Lake Road
Wayne, New Jersey 07470
Phone: (973) 696-1900
Fax: (973) 696-4211
Email: mail@massoodlaw.com