• Compliance Matters

    Physician Fee Schedule Coding Updates

    Changes for 2020 include new codes for dry needling and changes to a number of existing codes.

    This Compliance Matters column is being made available in advance of the rest of the February 2020 issue of PT in Motion magazine. Enjoy this published-ahead-of-print article now, and look for the entire February issue around the first of February 2020.

    Among the many provisions in the Centers for Medicare and Medicaid Services' (CMS) 2020 Medicare physician fee schedule are the following updates or additions to Current Procedural Terminology (CPT©) codes that physical therapists (PTs) often use to document their services.

    New Dry Needling Codes

    Two new codes are now used when a PT delivers dry needling. The code terminology for the procedure is "needle insertion without injection." They are:

    • 20560 — Needle insertion(s) without injection(s); 1 or 2 muscle(s)
    • 20561 — Needle insertion(s) without injection(s); 3 or more muscle(s)

    CMS has assigned these codes the status of "non-covered" services under Medicare. This means you will be able to bill a Medicare beneficiary directly for the services. Follow these procedures for submitting a claim to Medicare:

    • Provide a voluntary Advanced Beneficiary Notice to the patient
    • Include the appropriate code (20560 or 20561) on the claim
    • Append the GX modifier to indicate that you and the patient know the service is non-covered

    For state Medicaid and commercial payers, check the individual policies to determine which payers cover the procedure when billed by PTs, and whether those payers will use the new codes or have designated an alternative code for billing dry needling. Also, see the accompanying map identifying which states by law permit dry needling, which prohibit it, and which are silent on it. Because Medicare doesn't cover dry needling codes, CSM has not designated them as either "sometimes therapy" or "always therapy." "Always therapy" services must be furnished under the plan of care of a PT, occupational therapist (OT), or speech-language pathologist (SLP), regardless of who provides them. The codes always are accompanied by the appropriate GP (for PTs), GO (for OTs), or GN (for SLPs) modifier.

    Deleted and Replaced Codes

    CPT code 90911 has been deleted and replaced with codes 90912 and 90913, which describe:

    • 90912 — Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG [electromyography] and/or manometry when performed; initial 15 minutes of one-on-one patient contact
    • 90913 — Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry when performed; each additional 15 minutes of one-on-one patient contact

    This code change was prompted by a need to more precisely capture the time required to furnish this treatment to individual patients. These codes are identified as "sometimes therapy" services, meaning that qualified providers can furnish the services outside the plan of care of a PT, OT, or SLP. When the services are provided under a PT, OT, or SLP's plan of care, the codes must be accompanied by the appropriate GP, GO, or GN modifier.

    CPT codes 95831 through 95834 for manual muscle testing have been deleted. When a PT performs manual muscle testing during the same visit as an evaluation or reevaluation, it's considered part of the evaluation or reevaluation under codes 97161-97164. When a PT completes formal manual muscle testing and generates a report independent of an evaluation or a reevaluation visit, it's billed using CPT code 97750.

    CPT codes 97127 and G0515 have been deleted and replaced with CPT codes 97129 and 97130, which describe:

    • 97129 — Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes
    • 97130 — Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes

    In 2016, an untimed code, 97127, was approved for inclusion in the 2018 fee schedule. CMS subsequently developed timed code G0515, as there was concern that 97127 would not adequately capture the variability of time spent with a patient, potentially resulting in additional expenditures. CPT codes 97129 and 97130 were created to align with the CMS code description and accurately represent time spent in performance of the procedure.

    New E-Visit Codes

    The following are new digital assessment codes under the CPT-based Healthcare Common Procedure Coding System (HCPCS):

    • G2061 — Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time of 5-10 minutes
    • G2062 — Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time of 11-20 minutes
    • G2063 — Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time of 21 or more minutes

    Federal laws that govern Medicare specifically identify which practitioners may bill for evaluation and management (E/M) services. When new codes describe E/M services that fall outside of this category of eligible practitioners, CMS typically has created parallel HCPCS G-codes with descriptors that refer to the performance of an "assessment" rather than an "evaluation." Such is the case in the 2020 Medicare physician fee schedule.

    CMS established three new E/M codes for physicians, physician assistants, and advanced practice nurse practitioners to perform brief, online E/M services — CPT codes 98970, 98971, and 98972. The agency acknowledges that qualified nonphysician health care professionals likely will perform similar online digital e-visits, so it established parallel HCPCS codes G2061, G2062, and G2063, which mirror the recommendations of the American Medical Association's Relative Value Scale Update Committee (RUC) for CPT codes 98970-98972.

    Bell, Alice 75x110

    Alice Bell, PT, DPT, is a senior payment specialist at APTA. She is a board-certified clinical specialist in geriatric physical therapy