CMS Reverses Position, Will Reinstitute Damaging Coding Edits on October 1, 2020

The American Physical Therapy Association recently announced that CMS is moving ahead with damaging coding edits it had previously deleted.

This means that it will reverse course and reinstate previously deleted coding “edits” for code pairs that represent common and appropriate physical therapy practice.

As per the APTA, the return of the edits, lifted in April, run counter to best practice in physical therapy — a fact repeatedly brought to the attention of CMS and its coding contractor by APTA and other stakeholders.

A quick history of this is as follows:

At the start of 2020 it was announced that beginning January 1, 2020, as per the National Correct Coding Initiative (NCCI), when PTs and OTs bill an initial evaluation along with CPT code 97530 (therapeutic activities) and/or 97150 (group therapy) on the same date of service and for the same patient they will only receive payment for the evaluation. Using modifier 59 will not impact payment related to this change. 

These changes will also impact athletic training evaluations and re-evaluations. 

The change affects the following evaluative CPT codes:

  • 97161: PT evaluation – low complexity
  • 97162: PT evaluation – moderate complexity
  • 97163: PT evaluation – high complexity
  • 97165: OT evaluation – low complexity
  • 97166: OT evaluation – moderate complexity
  • 97167: OT evaluation – high complexity
  • 97169: Athletic training evaluation – low complexity
  • 97170: Athletic training evaluation – moderate complexity
  • 97171: Athletic training evaluation – high complexity
  • 97172: Athletic training re-evaluation

They also stated that if a provider bills one of the evaluation codes with CPT® 97140 (manual therapy) on the same date of service, then he or she must attach a 59 modifier to one of the codes in order to receive reimbursement.

These changes did not impact re-evaluation codes. These codes 97164 and 97168 already form edit pairs with the service codes included in this update, and those edits are still in place. In other word, if you billed 97164 with 97530 on the same date of service and the two services were provided separately and independently of one another you would need to affix modifier 59 to the re-evaluation code in order to receive payment for both services.

Not long after that changes came to this new rule. On January 24, 2020 CMS announced that it would remove what has been some of the most argued against changes to, for the most part, return to the coding rules used in 2019.

There were still issues that were not announced or worked out yet, however this meant that physical and occupational therapists will be able to return to billing for therapeutic activities (97530) delivered on the same day to the same patient as PT or occupational therapy evaluations billed under codes (97161, 97162, 97163, 97165, 97166, 97167). PTs (and occupational therapists) would also be allowed to return to billing the group therapy code (97150) with those evaluation codes.

This reversal was applied retroactively, starting with any relevant claims dated January 1, 2020, and CMS stated that providers would be able to recoup any payments lost as a direct result of the initial change. That said, as of the January 24 update, the changes involving CPT® code 97140 (manual therapy) were still in effect.

On April 21, 2020 the remaining NCCI changes were reversed, which meant therapists would no longer need to affix modifier 59 when billing 97140 with eval codes and other commonly-used CPT® codes (e.g., 97530 [therapeutic activities] and 97116 [therapeutic procedure]) on the same date of service. This change impacted all Medicare and Medicaid programs and was retroactive to January 1, 2020.

Recently CMS announced that the April 21st ruling will be reversed on October 1, 2020. As per the American Physical Therapy Association “Information about the reinstatement of these edits was not included in the files that were sent to health professional associations for review and comment, including APTA, offering the association no opportunity to comment on the change before it’s implemented on Oct. 1.”

It appears that many of the added pairs will be eligible for modifier 59 use, which means therapists will still be able to obtain reimbursement for both services when they are provided separately and independently of one another on the same date of service. According to billing experts at WebPT, here are some highlights:

  • The PT evaluation codes (97161–97163) and OT evaluation codes (97165–97167) are:
    • edited against (i.e., form edit pairs with) the code for manual therapy techniques (97140), but can be billed with modifier 59; and
    • also edited against codes 97750, 97755, 97763 as mutually exclusive and cannot be billed with a modifier.
  • The PT re-evaluation code (97164) and OT re-evaluation code (97168) are:
    • edited against 97750, 97755, 97763 as mutually exclusive and cannot be billed with a modifier.

This is the full list of updated edits for rehab therapy codes. If a code in Column 2 is followed by “y,” it can be billed with modifier 59 in combination with the code in Column 1. If a code in Column 2 is followed by “n,” it should not be billed in combination with the code in Column 1, as it will not be paid.

Column 1 Column 2
(y=use modifier 59; n=do not bill in combination with code from Column 1)
97012 97164y, 97168y
97016 97164y, 97168y
97018 97164y, 97168y
97022 97164y, 97168y
97024 97164y, 97168y
97026 97164y, 97168y
97028 97164y, 97168y
97032 97164y, 97168y
97033 97164y, 97168y
97034 97164y, 97168y
97035 97164y, 97168y
97036 97164y, 97168y
97039 97164y, 97168y
97110 97164y, 97168y
97113 97110y, 97164y, 97168y
97116 97164y, 97168y
97124 97164y, 97168y
97129 97164y, 97168y
97130 97164y, 97168y
97139 97164y, 97168y
97140 97164y, 97168y, 97750y
97150 97110y, 97112y, 97116y, 97164y, 97168y, 97535y, 97760y, 97761y
97161 97140y, 97164n, 97750n, 97755n, 97763n
97162 97140y, 97161n, 97164n, 97750n, 97755n, 97763n
97163 97140y, 97161n, 97162n, 97164n, 97750n, 97755n, 97763n
97164 97750n, 97755n, 97763n
97165 97140y, 97168n, 97750n, 97755n, 97763n
97166 97140y, 97165n, 97168n, 97750n, 97755n, 97763n
97167 97140y, 97165n, 97166n, 97168n, 97750n, 97755n, 97763n
97168 97750n, 97755n, 97763n
97530 97116y, 97164y, 97168y, 97535y, 97750y
97533 97164y, 97168y
97535 97164y, 97168y
97537 97164y, 97168y
97542 97164y, 97168y
97545 97164y, 97168y
97597 97164y
97598 97164y
97602 97164y
97605 97164y
97606 97164y
97607 97164y
97608 97164y
97750 95851n, 95852n, 97150n
97755 97035y, 97110y, 97112y, 97140y, 97530y, 97533y, 97535y, 97537y, 97542y, 97545y, 97750n, 97760y, 97761y, 97763y
97760 97016y, 97110y, 97112y, 97116y, 97124y, 97140y, 97164y, 97168y, 97763n
97761 97016y, 97110y, 97112y, 97116y, 97124y, 97140y, 97164y, 97168y, 97760y, 97763n
97763 97110y, 97112y, 97116y

It’s important to keep a close eye on these changes, as they are likely to impact payors beyond just Medicare and Medicaid. According to Alice Bell, senior payment APTA specialist, “Medicare and Medicaid programs must follow these edits, of course, but the damage is far greater than that,” Bell said. “Although some commercial insurers did not adopt the deletions in April those that did could also reinstate these edits. Providers should closely monitor any updates from these payers.”

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