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REVISED 2020 Medicare Physician Fee Schedule Now Available

January 9, 2020

The 2020 Medicare Physician Fee Schedule amounts were impacted by Federal legislation signed into law in late December. Because of this, our Medicare Contractor, NGS, temporarily removed the 2020 fee schedule from its website. As of January 8, the fee schedules have been updated on the NGS website.

Amounts on the updated fee schedule apply for dates of service on or after 1/1/20. Please discard previous versions of the fee schedule from the WCA which do not have the word "revised" at the top.

Click here to access the WCA 2020 Medicare Physician Fee Schedule Guide.

As a good rule of thumb, the WCA Help Desk suggests that you separate 2019 and 2020 dates of service on claims. In addition, if you are a Medicare Participating provider, you can file claims to Medicare with your full, regular fee and wait to see what comes back for the allowed amount.

In 2020, the annual Medicare Part B deductible will be $198 (an increase of $13 from 2019). Sequestration (2% reduction on covered charges) remains in effect until at least 2025 and takes place once the beneficiary has satisfied his/her deductible.

Humana Therapy Prior Authorization Requirement Does Not Apply to Chiropractors

January 6, 2020

Humana contracted providers recently received a document via fax detailing an upcoming prior authorization requirement for therapy services. The communication from Humana states that, "Effective Jan. 1, 2020 prior authorization from Optum/OrthoNet is required for all physical therapy, occupational therapy, and speech therapy providers, as well as any provider type billing one of the below CPT codes for Humana Commercial, Medicare Advantage, and dual Medicare‐Medicaid plan members." Contained within the list of impacted CPT codes are many therapy procedures which could be used within a chiropractic office, such as 97012, 97014, 97124, etc. However, the notice does state that services provided by chiropractors are excluded from Optum/OrthoNet management. More information about the Jan. 1 prior authorization requirement can be found in a Frequently Asked Questions document located here.

2020 Medicare Physician Fee Schedule UPDATE

December 30, 2019

In November, CMS released its Final Rule for the 2020 Medicare Physician Fee Schedule (MPFS). The conversion factor for 2020 was finalized at the proposed level of $36.09, a $0.05 increase over the $36.04 conversion factor for 2019 and thus impacts to individual CPT codes were expected to be very minimal (CPT 98940-98942 saw slight decreases). However, in the broader picture, on December 20, 2019 the President signed into law the Further Consolidated Appropriations Act of 2020 (FCAA) to fund the government through September 30, 2020 and avoid a government shutdown. One provision of the FCAA is that it extended the existing work geographic practice cost index (GPCI) floor under the Medicare program, set to expire on Dec. 31, 2019. The work GPCI is one component of the complex formula CMS uses to determine a final fee schedule amount for a procedure code. Each year, any of the variables can change, impacting the fee schedule. Because of this, our Medicare Contractor, NGS, has temporarily removed the 2020 fee schedule from its websiteAs of this morning (Jan. 6th) their fee schedule lookup tool is working, but we are waiting for official confirmation from NGS that the amounts are accurate. For the time being, we have removed our annual 2020 Medicare Physician Fee Schedule guide from our website, and will update all members once the final fee schedule is released.

As a good rule of thumb, the WCA Help Desk suggests that you separate 2019 and 2020 dates of service on claims. In addition, if you are a Medicare Participating provider, you can file claims to Medicare with your full, regular fee and wait to see what comes back for the allowed amount.

In 2020, the annual Medicare Part B deductible will be $198 (an increase of $13 from 2019). Sequestration (2% reduction on covered charges) remains in effect until at least 2025 and takes place once the beneficiary has satisfied his/her deductible.

What is Cultural Competency Training and is it Required? 

August 5, 2019

Last week, an email was sent by Optum Physical Health to Participating Providers asking them to re-validate their contact information as well as attest to whether or not they had undergone "cultural competency training." Other than stating that cultural competency training was a CMS requirement, the automated email provided no additional information and required recipients to electronically sign, or attest to whether or not they had taken this training. The WCA Help Desk reached out to Optum for additional information on this communication. We also asked our health care lawyer for her expert opinion.

The groundwork was laid for cultural competency to become a requirement by Title VI of the Civil Rights Act of 1964 as well as section 1557 of the Affordable Care Act. Both apply to any providers who receive Federal financial assistance, which would include payment from Medicare and Medicaid.

Title VI of the Civil Rights Act of 1964 mandates no discrimination in Federally subsidized programs or activities. Title VI applies no matter what amount of Federal money is involved. Protected classes include, but are not limited to: Race, Color, or National Origin (this includes primary language spoken in the household). When it comes to language, Title VI Requires “Meaningful Access” to Services for those whose primary language is not English. This is where the requirement to provide translation services (which applies to DCs) stems from. For more information on the requirement to provide translation to Limited English Proficient (LEP) individuals and those who are deaf/hard of hearing click hereSection 1557 of the Affordable Care Act protects against discrimination based on sex, age and disability.

Furthermore, 42 CFR § 438.10 mandates that health plans (such as UHC/Optum) that provide services to Medicare or Medicaid recipients must make available in paper form upon request and electronic form, the following information about its network providers:

(i) The provider's name as well as any group affiliation.

(ii) Street address(es).

(iii) Telephone number(s).

(iv) Web site URL, as appropriate.

(v) Specialty, as appropriate.

(vi) Whether the provider will accept new enrollees.

(vii) The provider's cultural and linguistic capabilities, including languages (including American Sign Language) offered by the provider or a skilled medical interpreter at the provider's office, and whether the provider has completed cultural competence training.

(viii) Whether the provider's office/facility has accommodations for people with physical disabilities, including offices, exam room(s) and equipment.

All of this leads one to wonder what standards apply to cultural competency training, and how does one determine if a particular training program is adequate? There are National Standards for Culturally and Linguistically Appropriate Services, or CLAS. These standards exist to inform health care providers about cultural differences in people, and how these differences impact the healthcare system.

“Published research from organizations like the Institute of Medicine, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention and more has shown that not only do people from different backgrounds have unequal access to care, but they also have disparities in health outcomes and in healthcare itself.” SOURCE: A Failure to Communicate - Caring for Patients with Limited English Proficiency – Dr. Robert Like, MD

Below are some different resources for cultural competency training. Regardless of the resource you use, you should document when you underwent the training in your compliance manual. Document when your staff takes the training as well, if applicable.

1) US Department of Health and Human Services (DHHS) National Standards for Culturally and Linguistically Appropriate Services (CLAS). Select the Administrators and Providers – Guide to Providing Effective Communication and Language Assistance Services.

2) UHC does offer online training on the UHC On Air site for participating providers including a course called, Impact of Cultural Competency and Americans with Disability Act Training. You must log in with your Optum ID to take this training.

3) The Wisconsin Department of Health Services offers various resources and training on cultural competency here:

4) U. S. National Library of Medicine - Health Services Research Information Central website. Health Literacy and Cultural Competence information including: News, Data, Tools and Statistics, Guidelines and Journals, Education, Meetings, Conferences and Webinars, Key Organizations.

***The bottom line is that while there is not a specific mandated cultural competency training class that healthcare providers must take, health plans are required by law to ask if participating providers have undergone this training on an annual basis. It is not a mandatory training nor will it remove providers from the network if not completed, it is only required for Optum to ask if it has been completed or not. Our advice at the WCA Help Desk is that cultural competency training is advisable to take from both a compliance as well as an ethical standpoint.

If you have specific questions on the Optum email that was sent to you, please contact Optum directly at 877-293-2046 or email and reference “physical health validation form.” 

Additional Resource(s):

Optum webpage on Cultural Competency:


UPDATE: Prior Authorization Requirement for PT Modalities "Delayed Temporarily" by Anthem BCBS

July 17, 2019


A July Wisconsin Provider Communications from Anthem BCBS informed Participating Providers that effective August 1, Physical Therapy, Occupational Therapy and Speech Therapy services will be subject to prior authorization review by AIM Specialty Health® (AIM).Just a short time later, a follow up communication dated July 16th from Anthem announced that the prior authorization requirement would be postponed until sometime after September.

The WCA reached out to Anthem BCBS to request additional information on the prior authorization review process and whether it applies to chiropractors performing physical therapy modality services, as well as what types of Anthem insurance plans it applies to. According to Anthem BCBS, the prior authorization requirement is code specific, not provider specific. Any qualified provider performing procedures contained within the list of impacted physical therapy CPT codes will be subject to the prior authorization requirement. Examples of CPT codes subject to the requirement include: 97010, 97012, 97014, 97110, 97112, 97124, 97140. So while the prior auth requirement for PT modalities does not apply at this point in time, we are monitoring communications from Anthem and will update members as information becomes available.

Below is more information about the policy that we have learned; however, keep in mind that it is not currently in effect & is subject to change:

As far as a timeframe for the prior auth process, AIM states that if the necessary information is provided, determinations are immediate in most cases. For more information, please see the AIM FAQs here.

AIM Prior Authorization Reviews of PT Modalities will utilize the Anthem Clinical Guidelines outlined here.


Providers may submit prior authorization requests to AIM in one of several ways:

  • Access AIM’s ProviderPortalSM directly at Online access is available 24/7 to process orders in real-time, and is the fastest and most convenient way to request authorization.
  • Access AIM via the Availity Web Portal at
  • Call the AIM Contact Center toll-free number at (800) 554-0580, Monday through Friday, 8:30 a.m. to 7:00 p.m. ET.

A complete list of the CPT codes that will be subject to prior authorization review can be found at the following link:


Humana Denying Therapy Codes for Lack of Modifier
April 23, 2019

A recent policy (click here to view) implemented by Humana requiring the -96 or -97 modifier on therapy codes has started to result in denials just this month. Here is what we know so far:

  • The policy was effective 1/1/18 but Humana only recently began implementing it in early 2019
  • The policy impacts Humana Individual policies and Small Group policies
  • The policy coincides with new modifiers created by the American Medical Association effective 1/1/18 to distinguish between rehabilitative and habilitative services.
  • Modifier 96 identifies habilitative services; modifier 97 identifies rehabilitative services.
  • Habilitative services are, “Health care services and devices that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical therapy, occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.”
  • Rehabilitative services are, “Health care services and devices that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings.”
  • Simply put, rehabilitative services help patients restore functions or skills that have been lost, while habilitative services develop skills and functions that had not been developed previously.
  • Since a chiropractor most often will administer rehabilitative services, then the modifier 97 will be used for Humana Commercial plans.  Modifier 96 and 97 should not be used together on the same claim.
  • Humana plans in the individual and small group markets have separate limits on rehabilitative and habilitative services.
  • For dates of service beginning on or after January 1, 2019, providers must append modifier 96 to procedure codes for habilitative services submitted for reimbursement & modifier 97 to procedure codes for rehabilitative services submitted for reimbursement. Claims submitted without these modifiers will be denied for lack of modifier.
  • Denied claims should be appealed. Click here for Humana's appeal process.
  • These modifiers should only be used for Humana individual and small group policies. We are not advising that you append modifier -97 to therapy claims for other insurance companies at this time.

Click here to read an article from Find-A-Code on the -96 and -97 modifiers.

Anthem Denials Update

 April 29, 2019 (updates are in RED)

Anthem BCBS has been keeping chiropractic offices across the state especially busy in early 2019. There have been a number of issues which have been resulting in claim denials.

1. Denials of procedure code G0283 being denied as investigational/experimental. G0283 is Electrical Stimulation, Unattended, one or more areas and is a covered code for Anthem BCBS.

  • Resolution: Denials were incorrect and an Appeal must be submitted in order to have the claim reprocess for payment.

2. Change in documentation guidelines to follow Medicare guidelines (i.e. documentation show pain, Outcome Assessments and functional improvement for all patients).

  • Resolution: We are still confirming if this applies in Wisconsin, since Anthem BCBS has different requirements by State. However, consider performing an internal audit on your Anthem BCBS documentation to ensure it is up to Medicare standards-this can only help you to show medical necessity.

3. Claim denials from Anthem BCBS due to the combination of diagnosis codes used being considered mutually exclusive.

Some of the code combinations that have been resulting in claim denials are:

 S33.140D and M53.2X7

S33.5XXA and M51.26 and also M51.36

  • Resolution: The Network Relations person we have been working with at Anthem states that Anthem updated their coding guidelines in December and communicated this with contracted providers. They specifically updated some codes which are considered mutually exclusive codes. This can often occur with the S codes. If you have any claim denials due to mutually exclusive diagnosis codes, the best fix would be to remove the code causing the error, replacing with another code that would be appropriate, and resubmit the claim. According to ChiroCode, “the S33.1- codes are controversial to many. Some feel that CMT is contraindicated for this diagnosis. Click here to read a ChiroCode article about the problem. Using the “S” diagnosis codes with other codes could appear to be contradictory since the "S" codes are for injuries. For example, if used with M51.37 Other intervertebral disc degeneration, lumbosacral region, the insurance carrier may question if this was this an injury or a degenerative condition? If the patient really did satisfy BOTH, you could appeal with the documentation of both conditions. However, it might be easier to simply submit a corrected claim with an M99- as the primary diagnosis.

The ICD-10 coding guideline was updated and communicated in December 2018 (see below communication from Anthem):


System updates for 2019 – Professional

 As a reminder, our claim editing software will be updated monthly throughout 2019 with the most common updates occurring in quarterly in February, May, August and November of 2019. These updates will:

  • reflect the addition of new, and revised codes (e.g. CPT, HCPCS, ICD-10, modifiers) and their associated edits
  • include updates to National Correct Coding Initiative (NCCI) edits
  • include updates to incidental, mutually exclusive, and unbundled (rebundle) edits
  • include assistant surgeon eligibility in accordance with the policy
  • include edits associated with reimbursement policies including, but not limited to, frequency edits, bundled services and global surgery preoperative and post-operative periods assigned by The Centers for Medicare & Medicaid Services (CMS)

Here is the reminder which was sent in February 2019 via Anthem's electronic Provider Updates:


Reminder: Review ICD-10-CM Coding Guidelines – Professional

 To help ensure the accurate processing of submitted claims, keep in mind ICD-10-CM Coding Guidelines when selecting the most appropriate diagnosis for patient encounters. Remember ICD-10-CM has two different types of excludes notes and each type has a different definition. In particular, one of the unique attributes of the ICD-10 code set and coding conventions is the concept of Excludes 1 Notes. An Excludes 1 Note is used to indicate when two conditions cannot occur together (Congenital form versus an acquired form of the same condition). An Excludes 1 Note indicates that the excluded code identified in the note should not be used at the same time as the code or code range listed above the Excludes 1 Note. These notes are located under the applicable section heading or specific ICD-10-CM code to which the note is applicable. When the note is located following a section heading, then the note applies to all codes in the section.


Hopefully you are signed up to receive the electronic updates from Anthem. If not, you can do so by visiting this link: and at the top of this page, click on “Subscribe to Email”.

4. Vague claim denials with explanation codes 066 and/or 45:

  • Resolution: Anthem has an analytics company called Cotiviti, who assists Anthem BCBS is implementing correct coding guidelines. Anthem is aware that there is an issue with the denial reasons not appearing on the EOB’s for claims that Cotiviti is examining. They state that this is a project that is being worked on and they are looking at resolution by the end of 2nd quarter (June 30th). In the meantime, if you receive any claim denials, we suggest contacting customer service and asking for clarification. Medical records may be needed.

5. E/M codes being denied when billed with an adjustment code

When billing an E/M code with an adjustment, it is necessary to append the -25 modifier to the E/M code. However, many payors will audit claims with modifiers such as 25, 51 and 59 to ensure that the code with the modifier in question meets the criteria for using that modifier.

Anthem BCBS states they are implementing this policy and that it applies to all providers.

Click here to read a recent article from Find-A-Code on E/M bundling.

We suggest appealing any denied exams. You may use our template appeal letters to help save time, click here for the template appeal letters (Note: you must be signed in with your WCA member user name and password to access).