Sudden NCCI Edits for Physical and Occupational Therapy

National Correct Coding Initiative

The NCCI is making changes to the CPT code

Starting 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 state 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 do 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.

Historically the NCCI alerts the APTA in advance to upcoming changes. This, however, did not occur as per the APTA. According to the American Physical Therapy Association “APTA usually receives notice of intended NCCI edits well in advance. That didn’t happen in this case, making it imperative that the association, its members, and other stakeholders take action quickly to convince NCCI to reverse its decision. APTA is in communication with Capitol Bridge, LLC, CMS’ NCCI contractor, as well as with the American Medical Association, to press for a resolution to the problem.”

According to APTA Director of Regulatory Affairs Kara Gainer, the changes ignore accepted therapy practice, which often includes the startup of care on the same day as evaluation, as well as continuation of care on the same day as revaluation. “The whole NCCI process is supposed to put a check on payment for codes that represent overlapping services,” Gainer said. “These edits not only miss that mark, they actually have the effect of restricting patient access to the most effective, efficient care, and risking a patient’s ability to achieve the best possible outcomes.”

It is important to be aware that these changes do not only apply to Medicare insured patients. In fact, all insurance carriers that follow NCCI rules are following the new rules. It is possible that some insurances may implement these changes later than others, and there is a chance that if they do implement the changes later, they will recoup any affected claims/payments. 

Compliance expert Rick Gawenda stated: “Insurance companies that were using NCCI edits in 2019 are most likely using them in 2020”.

Many clinicians and companies were unpleasantly surprised by this sudden change. The APTA strongly encouraging all rehab therapy professionals to advocate on behalf of the profession. The have developed this comment letter template to fill out with your information and email to Capitol Bridge, LLC at


Capitol Bridge, LLC

National Correct Coding Initiative Contractor

PO Box 368

Pittsboro, IN 46167

Submitted electronically:

To Whom It May Concern:

As a member of the American Physical Therapy Association, I am writing to express my deep concern regarding proposed NCCI PTP edits that become effective January 1, 2020. Physical therapists play a unique role in society in prevention, wellness, fitness, health promotion, and management of disease and disability by serving as a dynamic bridge between health and health services delivery for individuals across the age span. While physical therapists are experts in rehabilitation and habilitation, they also have the expertise and the opportunity to help individuals improve overall health and prevent the need for avoidable health care services. Physical therapists’ roles may include education, direct intervention, research, advocacy, and collaborative consultation. These roles are essential to the profession’s vision of transforming society by optimizing movement to improve the human experience.

CMS developed the NCCI to prevent inappropriate payment of services that should not be reported together. One function of NCCI PTP edits is to prevent payment for codes that report overlapping services except in those instances where the services are separate and distinct. 

Physical therapists currently are challenged in the appropriate delivery of care by three existing problematic edits. The American Physical Therapy Association has requested reconsideration of these edits in order to ensure that patients are able to receive necessary services during a single treatment session.

97530 97116 Mutually Exclusive

97530 97113 Mutually Exclusive

97140 97530 Mutually Exclusive

In addition to the above edits, the January 1, 2020, NCCI PTP edit file includes new edits that will further limit appropriate care and are inconsistent with the edit model:

CPT codes 97150 and 97530 are now listed as a column one code with all the physical therapy and occupational therapy evaluation and reevaluation codes (97161-97168) and are not permitted to be billed on the same day as a physical or occupational therapy evaluation.

Additionally, there is a new edit requiring a modifier 59 for CPT 97140 when billed with a physical therapy or occupational therapy evaluation.

The above edits conflict with current CMS policy. As stated in Chapter 15 of the Medicare Benefit Policy Manual, “The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits. It is appropriate that treatment begins when a plan is established.”

Standard physical therapist practice includes the initiation of care on the same day as an evaluation and the provision of care on the same day as a reevaluation whenever possible. Physical therapists identify the issues or conditions requiring treatment during the examination/evaluation and work to implement treatment at the same time. Given the very limited number of physical therapy sessions available to a patient, each visit with a physical therapist must be maximized to ensure that the patient has the best opportunity for recovery. Patients who present with pain, fall risk, mobility issues, challenges performing activities of daily living, or the inability to execute their employment-related tasks require immediate intervention. Any delays in care can negatively impact the ultimate outcome of care. 

The edits identified in the new edit tables restrict access to care and ultimately reduce the opportunity for patients to achieve the best outcomes. What’s more, there is no indication from CMS, practitioners, or patients that the absence of these edits has led to the misappropriation of care and/or undue reimbursement. 

I have significant concerns that the new edits fail to align with the current practice of care and will cause undue hardship on Medicare providers and beneficiaries. In an effort to limit the administrative and financial burden on Medicare beneficiaries as well as on Medicare providers, and to better support the effective and efficient treatment of a patient’s condition, avoid delay of a meaningful intervention, and prevent the need for an otherwise unnecessary follow-up visit, I strongly recommend that Capitol Bridge, LLC and CMS remove the proposed edits described above. 


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