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  • Payment Win: CMS Reverses Most of Its Damaging Coding Edits, More Details to Come

    The issue: On January 1, CMS changed some of its correct coding methodologies in ways that prevented PTs from billing an evaluation and therapeutic activity and/or group therapy services delivered on the same day, a common practice in physical therapy.

    The news: APTA and its members engaged in extensive advocacy efforts to convince CMS to rethink its decision. On January 24, CMS announced that it would do away with the most problematic changes and, for the most part, return to the coding rules PTs used in 2019.

    What it means: PTs 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) will also be allowed to return to billing the group therapy code (97150) with those evaluation codes.

    Keep in mind: There are still lots of details to be worked out, including the timeline for CMS to notify Medicare Administrative Contractors of the change, and whether it's retroactive. Additionally, a few of the January 1 restrictions remain, primarily related requirements around use of the 59 modifier/X modifier.

    The pressure paid off
    After a concerted effort by APTA, its members, and other stakeholders, CMS relented on the most detrimental parts of its changes to the edits that prohibited payment for certain activity codes if they're used on the same day as evaluation codes. The win means that PTs will be able to, for the most part, return to coding practices that were in effect prior to January 1, 2020. CMS has not yet shared details on effective date and the process for implementation of the changes.

    CMS has not yet shared details on effective date and the process for implementation of the changes.

    In a January 24 letter to APTA and other associations, Cathy Cook, MD, medical director of CMS coding contractor Capitol Bridge, wrote that "after reviewing this issue more closely, CMS has made the decision to retain the edits that were in effect prior to January 1, 2020."

    The return to the pre-January 1 coding environment reverses a CMS National Correct Coding Initiative edit that prevented PTs and OTs from billing for therapeutic activities (97530) if any of the PT or OT evaluation codes were billed the same day for the same patient. That prohibition crossed disciplines that use the same provider number, which prevented, for instance, an OT for billing for therapeutic activities with a particular patient on the same day a PT in the same practice billed for evaluation of the patient. In addition, CMS applied restrictions on billing for group therapy on the same day as PT or OT evaluations.

    With the letter from Capitol Bridge, those restrictions were undone.

    "The coding edit CMS imposed on January 1 not only ran counter to best practice in physical and occupational therapy, but was not consistent with CMS' own stated goals for care," said Kara Gainer, APTA's director of government affairs. "APTA and its members conveyed that message in large numbers, and in no uncertain terms. We're extremely pleased that CMS listened to the case we made and did the right thing for patients."

    While the reversal eliminated the most problematic parts of the January 1 edits, a few restrictions still remain: CMS will continue to require the 59 modifier/X modifier to be applied if a PT wants to receive payment for furnishing both manual therapy (97140) and an evaluation using any of the physical therapy evaluation codes (97161, 97162, 97163) on the same day for the same patient, or if billing for therapeutic activities (97530) or group therapy (97150) delivered on the same day as a physical therapy reevaluation (97164).

    The letter from Capitol Bridge also states that CMS will provide further information when it becomes available regarding impacted claims. Other details, such as how and when Medicare Administrative Contractors will be notified of the change, are unclear as of publication of this article. APTA will provide details as they become available.

    Katy Neas, APTA's executive vice president of public affairs, says that even with the remaining restrictions, the reversal from CMS is a significant one.

    "It's never easy to undo something that's been imposed by CMS and is already up and running," Neas said. "The fact that CMS changed course so quickly on so many of the most damaging parts of the coding edits is a testament to what can happen when APTA, its members, and stakeholders speak with a unified voice."

    Questions about where things stand in the wake of the CMS change? Contact advocacy@apta.org.


    • This is why I’ve been an APTA member since 1978—fighting for the profession I love so much! Thank you!!!!

      Posted by Patricia Kocich on 1/24/2020 4:53 PM

    • Well done APTA in your rapid identification of the issue and providing effective tools for stakeholders to communicate the need for reconsideration. I appreciate your vigilance and expertise in crafting the compelling response related to patient needs and established, high quality practice patterns. Thank you for keeping our patients and our gold standard of care in razor focus.

      Posted by Karen Frederick on 1/24/2020 5:41 PM

    • This is great news! Thanks to all who stood up to make the change so our profession can keep moving forward and making people functional, happy, healthy and moving to the best of their abilities once again...without restrictive coding!

      Posted by Kristen Collins on 1/24/2020 8:30 PM

    • This is awesome. Am glade they are listening. I just wish they could reverse some of these changes that has occurred with PDPM because it’s interfering with quality of care for patients. It’s seems like it’s quantity over quality. If something is not done soon, it’s going to be more therapist versus jobs and a shortages of therapist when they are really needed. People are going to stop going to school for therapy.

      Posted by Octavia Spiller on 1/24/2020 9:35 PM

    • This is awesome ! Do not give up -

      Posted by Kirat shab on 1/24/2020 9:35 PM

    • Thanks for all of the hard work and due diligence

      Posted by Susan Gerhard -> =LUc< on 1/25/2020 9:55 AM

    • Good job APTA!!! Now I have some faith in my organization again that I have been a member of since 1984. Let's keep that pressure on and get APTA to rescind the 8% payment cut for 2021.

      Posted by Tim Bonack on 1/25/2020 10:08 AM

    • Great job to all who advocated for this. Now let’s fight for our PTA’s, and the changes that are being imposed on us. Thanks to all who stand behind us, and our profession on a daily basis.

      Posted by Ann Marie DeAntonio on 1/25/2020 10:45 AM

    • Great advocacy from change with codes!!! I wish this same advocacy could be seen with PDPM. I am waiting for APTA and AOTA to use their power to make these changes. All therapists could really use your help. Decrease in hours, unrealistic productivity and forced groups cause out patients not to get the therapy the deserve. PLEASE HELP US!!!

      Posted by Chris Dillon on 1/25/2020 8:01 PM

    • This is all well and great for the world of outpatient therapy and I’m happy those therapists are being fought for, but it would be nice to read that the APTA is actually fighting for the other thousands of therapists losing their jobs because of the horrors of PDGM and PDPM. These Medicare changes have pretty much made the therapists in these areas go extinct. I went from seeing on average between 25-35 patient visits a week for the last 14 years down to 9 visits this week. Next week is even less. I had found my calling and passion in the area of home health and it has been completely destroyed and taken from me in the blink of an eye. This is happening to thousands of therapists. Many of those therapists are leaving the industry all together in order to survive. And I have yet to read that anything is being done or fought for by APTA to help. The patients needs aren’t being met and the therapists are suffering. So APTA, how about you help us now??!?

      Posted by Samala LaMartina on 1/26/2020 1:36 AM

    • As usual, the APTA picks and wins the insignificant battle. The APTA goes to war over the inability to bill 97530 with an initial eval which can largely be solved by using a form of therex and billing 97110. In the meantime, the APTA ignores the 2022 15% cut on PTA payments and CMS's invitation to comment on changing onsite to offsite supervision of PTAs. Both of which would have much larger impact on outpatient practice.

      Posted by CARY EDGAR on 1/27/2020 9:17 AM

    • Great Job APTA advocates, thank you for jumping in the fire. I am proud to be a member since 2010.

      Posted by Diane Uhri, PT, DPT on 1/27/2020 9:42 AM

    • We have an amazing profession and happy to see a fight won in the best interest of our patients. I have been a member of the APTA my entire career, since 1983, and will continue to support our profession and those who represent us at a higher level. Thank you!!!

      Posted by Donna Clark on 1/27/2020 6:31 PM

    • Great job APTA. Thank you to all our advocates that contributed to this good news.

      Posted by Connie Chiu on 1/27/2020 7:33 PM

    • Thank you, APTA and fellow PTs for making this a positive result for our profession. I am proud to me a member for over 35 years!

      Posted by Theresa Schmidt on 1/27/2020 9:21 PM

    • I second Cary Edgar's sentiment. This was a win, but insignificant. It reminds me of the APTA celebrating on "eliminating the therapy cap." Which in reality it lowered it to a soft threshold of $3000 from $3800, and gave CMS the ability to perform RAC audits if they deem your billing practices abnormal. Oh, and that elimination of the therapy cap led to the law mandating 85% reimbursement for PTA services. Have to love the APTA spinning information to pat themselves on the back.

      Posted by Anonymous on 1/28/2020 7:41 AM

    • This is why I will maintain my APTA membership! Next reverse patient-driven groupings model that started 01/01/2020. Thank you all!

      Posted by Ayat Abe on 1/28/2020 9:34 AM

    • Thank You to the staff at APTA always keeping us informed. We could not practice in today's space with confidence without this vital source of current information.

      Posted by jane eliasson on 1/28/2020 9:45 PM

    • Well done, this is why I have been a member for over 30 years and a contributor to PAC. Thank you

      Posted by Fernando Suarez PT on 1/29/2020 1:06 PM

    • Thank you APTA. The collective effort is the exact reason I’ve been a member for 16yrs, since being a student.

      Posted by J on 1/29/2020 10:59 PM

    • I agree with much of the sentiment above, another rather insignificant win, like getting a participation trophy in little league. There are much larger issues as mentioned by the people above that have huge impacts, both financially and logistically to outpatient PT ex. The cap reduction, PTA reduction, on-site supervision required for PTA’s, payment reductions coming in the subsequent years, RAC audits, it is truly a joke! Quite honestly it is the reason I decided two years ago to stop giving my hard earned $500 a year to an organization that has consistently allowed us to come up with the short end of the stick.

      Posted by Anonymous on 1/31/2020 5:24 AM

    • "...APTA ignores the 2022 15% cut on PTA payments and CMS's invitation to comment on changing onsite to offsite supervision of PTAs. Both of which would have much larger impact on outpatient practice." Right on Carey "The cap reduction, PTA reduction, on-site supervision required for PTA’s, payment reductions coming in the subsequent years, RAC audits," Ditto Anonymous. I have a private practice, we bill a manual, maybe a TE or TA. Not a biggie for me. Not thinking about this one at all especially since it was just for the low complexity. The other 8% cuts are SWEEPING! Get it together APTA and stop patting yourself on your back. Samala, sorry for your luck in HH, hire a PTA to provide care, they don't need PT supervision by you after your IE, ours still do!

      Posted by Joe on 1/31/2020 7:30 PM

    • Great effort and outcome. Thank you. The code 97530 was needed for educating patients on the day of evaluation, along with implementing changes in their posture and movement habits etc. That's speeding up recovery, more savings for the patient and insurance companies.

      Posted by Beata Smela on 2/2/2020 10:09 PM

    • Great now please go after the disasters of Anthem and United Health Care for the private practice settings.

      Posted by Thomas P Nelson on 2/6/2020 9:28 AM

    • We received a denial from a BCBS plan on the eval charge. They paid the 97530 but not the eval citing the CCI edits. Will cci edits that all ins can use be updated or just CMS? Trying to know if I should see this claim redone.

      Posted by Heather on 2/24/2020 11:28 AM

    • @Heather: please contact us at advocacy@apta.org to discuss. Thanks!

      Posted by APTA staff on 2/25/2020 1:14 PM

    • Have gotten denial on several claims, not paying the eval. Any ideas on when this the rollback should be inplemented? Should I resubmit claims?

      Posted by Emilee on 3/10/2020 1:55 PM

    • Still a problem with reimbursement. What is the hold up? Fast to implement but slow to change. Enough

      Posted by Michelle Guevin -> >KQa= on 3/17/2020 9:35 PM

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