Monday, November 24, 2014

Modifier 59 Use – Outpatient Therapy Services

Dan Ciolek

Recently there has been some confusion among providers of Part B therapy services regarding how to properly comply with the National Correct Coding Initiative (NCCI) edits. On August 15, CMS released Change Request 8863 and the related MLN Matters article MM8863 – Specific Modifiers for Distinct Procedural Services. These documents discuss changes to HCPCS modifier -59, which become effective January 1, 2015. Modifier -59 is used to define a “Distinct Procedural Service” and indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. CR8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier:
· XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter,

· XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure,

· XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and

· XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.

In response to provider questions regarding whether these new modifier codes should be used for outpatient therapy services, CMS provided the following guidance to AHCA and other organizations to share with providers: 

Re: CR 8863 & MM 8863 – Specific Modifiers for Distinct Procedural Services

 · CMS is establishing four new HCPCS modifiers to define subsets of the 59 modifier, a modifier used to define “Distinct Procedural Services”

· The four new modifiers:

o XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

o XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure

o XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner

o XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service 

At this time, the below statements represent CMS policy about the use of the new X{EPSU} modifiers for therapy services; and, is being sent in response to inquiries about their use on claims for therapy services.  

The following information regards the new X{EPSU} modifiers and their use with therapy procedures and the National Correct Coding Initiative (NCCI) edits: 

· You can keep using the 59 modifier until CMS issues specific instructions about the use of the new X{EPSU} modifiers.  

· Because the X{EPSU} modifiers were developed to be used in the place of the 59 modifier, the XP modifier (used to indicate a different “practitioner”) is not appropriate to use [at this time] to distinguish between therapy disciplines as CMS uses the therapy modifiers — GN, GO, or GP — to track and differentiate between the 3 therapy disciplines.  

· For purposes of applying the NCCI edits for outpatient therapy services, you can continue to use the 59 modifier, rather than the X{EPSU} modifiers, to denote distinct therapy procedures until such time CMS issues future clarifying instructions.  

If you have questions please contact Dan Ciolek at  

Wednesday, November 19, 2014

NCAL's Art for the Ages Submissions- Deadline Fast Approaching

Rachel Reeves

Help us celebrate the many talented artist-residents in assisted living communities by participating in NCAL’s Art for the Ages! Submissions of residents’ artwork is being accepted through November 30.

How to Submit:
Take a digital photograph of your residents’ best artwork. This can be any artwork completed at any time throughout this past year. Images from smart phones and other portable devices will still be accepted, but high quality images are appreciated.

Get your residents’ approval. Each artwork must have a corresponding resident signed authorization form. Please have your resident sign the form, scan it and email it to NCAL along with your photos.
Send your submission to NCAL. Email photo(s) of residents’ artwork and signed authorization forms to NCAL’s Director of Communications, Rachel Reeves: Please include a sentence or two describing your photo (the resident who created the piece, the activity you were holding at the community, etc.) 

Learn more at and check out previous years’ submissions on AHCA/NCAL’s Pinterest boards.

Submit today! This is a great opportunity to showcase amazing residents, as well as the fantastic activities assisted living communities offer.


Secretary Burwell announces Region IX Director of HHS

Dana Halvorson

On November 19, 2014, U.S. Health and Human Services (HHS) Secretary Sylvia Burwell announced the appointment of Melissa Stafford Jones as the Region IX Regional Director. According to the press release on the announcement, as a Regional Director, Stafford Jones will serve as a key representative of the Department of HHS in working with federal, state, territorial, local, and tribal officials on health and social service issues, including implementation of the Affordable Care Act. The Region IX office is based in San Francisco, and works with officials in Arizona, California, Hawaii, Nevada, Guam, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Republic of Marshall Islands and the Republic of Palau.

House Elects Leadership and Committee Heads

Drew Thies

The House voted this week to elect its parties’ leadership and committee heads this week, with every member running for reelection winning their race.

The top two members of each party—reps. John Boehner (R-OH) and Kevin McCarthy (R-CA) for the Republicans and reps. Nancy Pelosi (D-CA) and Steny Hoyer (D-MD) for the Democrats—will remain the same in the 114th Congress. Boehner, however, still faces a vote for Speaker of the House upcoming in January when the new session begins.

The retirements of Reps. Dave Camp (R-MI) and Henry Waxman (D-CA) opens up top spots on Ways and Means and Energy and Commerce, respectively. 

The race for the top Democratic seat on the Energy and Commerce committee was tightly contested, where Rep. Frank Pallone (D-NJ) ran against Rep. Anna Eshoo (D-CA). Pallone is more senior on the committee but Eshoo was backed vocally by Leader Pelosi. In party elections today, Pallone edged out Eshoo by a vote of 100-90 among chamber Democrats.

Republicans elected Rep. Paul Ryan (R-WI) to take the gavel at the head of the Ways and Means committee, a move many expected would happen.

Returning chairs and ranking members kept their spot on the two committees. Rep. Frank Upton (R-MI) remains the Chair of the Energy and Commerce Committee and Rep. Sander Leven (D-MI) will continue his tenure as the Ranking Member on Ways and Means.

Free Clinical Practice Webinar Series from AHCA/NCAL

Holly Harmon

Throughout 2014, the Clinical Practice Committee designed a series of free webinars focused on various areas of clinical practice that support the AHCA/NCAL Quality Initiative goals to safely reduce hospital readmissions and the off-label use of antipsychotic medications. These webinars are available on demand so they can be viewed at all hours. The Clinical Practice Series offers webinars useful to all members in the interdisciplinary team including three part reducing rehospitalizations, eight part falls management & prevention, two part antipsychotic medication management & reduction, and considerations for end of life care.

Click here to view all the webinars that have been recorded as a part of the series.

Make the AHCA/NCAL Quality Symposium Your First Conference of the New Year

Jon-Patrick Ewing

With the holidays coming, vacations starting and year-end responsibilities adding up, don't wait any longer, register now for the AHCA/NCAL 7th Annual Quality Symposium: It's Time to Roar! This year’s symposium is schedule for February 23-25, in Austin, Texas.

Registration Deadline: Friday, January 23, 2015

Commit now, and start the new year off with an ongoing, renewed or even a new dedication to performance excellence for yourself, your center and your residents! The symposium provides tools and information at all levels and is an unique and highly-engaging, peer-to-peer learning experience.

What’s in store for this year’s attendees?

· 20 concurrent sessions over three days

· Potential to earn up to 15.5 CEUs

· Hear from inspiring Opening General Session Keynote, Terry Barber

· NEW! LED Talks. These are similar to the popular TED Talks but our version stands for, LEAD, ENGAGE and DISCOVER. Ten topics and ideas that are provocative, inspirational, and sometimes disruptive – all covered in 18 minute individual sessions! Curated by Provider magazine.

· NEW! Sponsor Supported Education Sessions: Join our sponsor partners at Sponsor Supported Education Sessions. These three sessions will feature information about how products/services have contributed to successful quality improvement efforts within their customer community. 

· Registration includes choice of one Intensive Session (four available)

· Quality Initiative Recognition Program Ceremony: Celebrate the incredible success of our state affiliate innovation award recipient and the over 7,000 nursing center or assisted living communities that have met one or more of the AHCA and NCAL Quality Initiative goals.

Reimbursement Resources Available to AHCA/NCAL Members

Abigail Horn

The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) provides many resources for members to help navigate a variety of Medicare and Medicaid issues. Visit the AHCA/NCAL website to check out these available toolkits:

· Medicaid Long Term Services and Supports (MLTSS) Toolkit – This toolkit is based on guiding principles that AHCA believes must be part of any Medicaid MLTSS program. It includes suggestions for statutory, regulatory or contractual agreement language, as well as a checklist of points to review in MLTSS plan contracts.

 · Medicare Advantage Toolkit – This toolkit consists of three modules designed to guide providers through the basics of the Medicare Advantage program and strategies for contracting between providers and plans. The first module provides an overview of the MA program, while the second module does a deep-dive in how plans are reimbursed by the government and how they, in turn, reimburse providers. The final module is a model contract with a discussion of necessary provisions you should be aware of before entering negotiations.

 · Accountable Care Organization Toolkit – This toolkit was developed for providers who are considering entering into contractual relationships with one or more of Medicare’s Accountable Care Organizations (ACOs). The guide is divided into three parts: a primer on the ACO program, a robust discussion to help providers prepare for and negotiate with ACOs and a model contract with discussion around discrete provisions providers should consider when negotiating with ACOs.

· State of the States Clearinghouse – This toolkit provides members with access to key Medicaid and Medicare information. The Clearinghouse is a one stop shop for valuable state-specific data impacting the long term care profession. View this short webinar to learn more about this tool.

AHCA/NCAL will continue to provide new resources in 2015 focused on the issues that matter to our members, such as Fraud and Abuse, MLTSS Contracting and more. Look for more updates to come in the New Year!

Monday, November 17, 2014

2015 AHCA/NCAL Convention Call for Presentations

Teresa Eyet

Don’t miss your chance to submit a proposal idea during the 2015 call for presentations period. Proposals will be accepted through November 30, 2015. Submission information and guidelines as well as the link to the submission database can be found at and click on 2015 Call for Presentations.

ICD-10 Updates

 Dianne De La Mare

As reported previously, the US Department of Health and Human Services (HHS) has released a final rule setting Oct. 1, 2015, as the new compliance date for health care eproviders, health plans and health care clearinghouses to transition to ICD-10. During the upcoming MLN Connects National Provider call on Nov. 5, 2014, CMS subject matter experts discussed ICD-10 implementation issues, opportunities for testing and federal government developed resources. To see schedule for additional calls go to

Further, the Centers for Medicare & Medicaid Services (CMS) has updated five ICD-10 previously released learning tools including: 1) ICD-10-CM/PCS Billing and Payment Frequently Asked Questions at;
2) ICD-10-CM/PCS The Next Generation of Coding at;
3) ICD-10-CM/PCS Myths and Facts at; 4) ICD-10-CM Classificaiton Enhancements at and
4) General Equivalence Mappings Frequently Asked Questions at; and
5)General Equivalence Mappings Frequently Asked Questions at

Lastly, to help providers prepare for the transition to ICD-10, CMS offers acknowledgement testing for current direct submitters (e.g., providers and clearinghouses) to test with their Medicare Administrative Contractors (MACs) and Common Electronic Data Interchange (CEDI) anytime up to the Oct. 1, 2015, implementation date. To participate in testing, go to your MAC website or through your clearinghouse. Any provider who submits claims electronically can participate in acknowledgement testing.

During the testing process, expect to: 1) test claims with ICD-10 codes and within the current dates of service; 2) test claims will receive the 277CA or 999 acknowledgement as appropriate, to confirm that the claim was accepted or rejected in the system; 3) Testing will not confirm claim payment or produce a remittance advice; and 4) MACs and CEDI will be staffed to handle increased call volume during the testing period.

 To obtain more information on acknowledgement testing and how to participate go to MLN Matters Article MM8858 at

OIG Releases 2015 Work Plan

Dianne De La Mare

The US Department of Health and Human Services (HHS), Office of Inspector General (OIG), has released its 2015 work Plan, which summarizes new and on-going OIG reviews, audits and other activities that the agency plans to pursue in FY 2015. OIG was created to protect the integrity of HHS programs and operations and the well-being of beneficiaries by detecting and preventing fraud, waste and abuse; identifying opportunities to improve program economy, efficiency and effectiveness; and holding accountable those who do not meet program requirements or who violate federal health care laws. The FY 2015 OIG Work Plan acts as a guide for AHCA/NCAL membership, identifying the specific areas where long term care and post-acute care providers can expect OIG focus and involvement. For skilled nursing facilities (SNFs), OIG plans to review the following areas:

· Medicare Part A billing by skilled nursing facilities – OIG will describe changes in SNF billing practices from FYs 2011-2013. Prior OIG work has found that SNFs increasingly billed for the highest level of therapy even though beneficiary characteristics remained largely unchanged. Expected issue date of this report is due in 2015.

· Questionable billing patterns for Part B services during nursing home stays – OIG will identify questionable billing patterns associated with SNFs and Medicare providers for Part B services provided to residents during stays not paid under Part A. For example, stays during which benefits are exhausted or the 3-day prior inpatient stay requirement is not met. Expected issue date of this report is due in 2015.

 · State agency verification of deficiency corrections – OIG will determine whether state survey agencies verified correction plans for deficiencies identified during nursing facility (NF recertification surveys. Prior OIG work has found that one state survey agency did not always verify that NFs corrected deficiencies identified during surveys in accordance with the federal requirements. Expected issue date of this report is due in 2015

· Program for national background checks for long-term-care employees – OIG will review the procedures implemented by participating states for long term care facilities or providers to conduct background checks on prospective employees and providers who would have direct access to patients and determine the costs of conducting such background checks. Expected date of this report is due in 2015.

 · Hospitalizations of nursing home residents for manageable and preventable conditions – OIG will determine the extent to which Medicare beneficiaries residing in NFs are hospitalized as a result of conditions thought to be manageable or preventable in the NF setting. Expected issue date of this report is due in 2015.

For assisted living facilities (ALFs), OIG has plans to review Hospices in ALFs settings. For home health (HH) services, OIG has plans to review Home health prospective payment system requirements and Employment of individuals with criminal convictions.

To obtain a copy of the full OIG Work Plan FY 2015 go to