Appeal type: Outpatient Therapies
Decision: Partially Favorable

 
We decided that the Plan has to pay for procedure codes 97110, 97112, 97116, 97530, 97535, and six units of 
97116. We decided that the Plan does not have to pay for one unit of procedure code 97166.  
 
You asked the Plan to pay for therapy services (97110, 97112, 97116, 97530, 97535 and 97166) provided from 
July 4, 2022, to July 30, 2022. You say that these services were billed appropriately. The Plan says that line 65 
(procedure code 97166) was billed without the necessary GO modifier. This claim is denied as it was not billed 
in accordance with Medicare billing guidelines. In addition, due to this error this claim is considered 
incomplete and therefore no part of this claim is processable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The 
rules say that certain therapy codes must be reported with the GN, GO, or GP modifier to distinguish the 
discipline of the plan of care under which the service is delivered. The rules also say that a claim may be 
returned to the provider for correction if there is required information which is invalid or incomplete. 
 
We decided that the Plan has to pay for procedure codes 97110, 97112, 97116, 97530, 97535, and six units 
of 97116.  
 
We looked at the file and Medicare rules. The Plan denied this claim as a whole on the basis that a single claim 
line is missing a modifier. Although a modifier may be necessary to process any specific claim line, it is not 
considered required information in this scenario. Required information is defined as any data element that is 
needed in order to process a claim, specifically, Provider Name or Date of Service. A claim could not be 
processed if required information, such as to whom payment should be made, who received services or the date 
they were performed, were absent. This claim is submitted under the Physician Fee Schedule and includes the 
required information to process this claim. It is not appropriate to deny this claim as a whole due to a single 
claim line error. Based on this information, we have determined that the rules for billing these services have 
been met. Therefore, we decided that the Plan has to pay for procedure codes 97110, 97112, 97116, 97530, 
97535, and six units of 97116.  
 
We also decided that the Plan does not have to pay for one unit of procedure code 97166. 
 
We looked at the file and Medicare rules. Code 97166 as billed on line 65 was submitted without modifier GN, 
GO, or GP, although this code is among those which require one of these modifiers. Based on this information, 
we have determined that the rules for coverage of code 97166 have not been met. Therefore, we decided that 
the Plan does not have to pay for one unit of procedure code 97166. 
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.