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  • CMS Coding Reversal Will Apply to Claims Made Beginning January 1, 2020

    Details are still emerging around exactly how CMS intends to walk back a decision to change coding methodologies that prevented PTs from billing an evaluation performed on the same day as therapeutic activities and/or group therapy activities. But we know a little more now: namely, that the decision is retroactive to January 1 of this year, the date when the short-lived system was set in place.

    APTA pressed CMS for the logistics of how its do-over would be worked out as soon as its decision was announced on January 24. On January 28, CMS informed the association that while the agency is still working on its messaging to the Medicare administrative contractors, or MACs, the reversal will be extended to claims made from January 1, 2020, on.

    The current state of flux leaves physical therapy providers with three basic options: delay submitting claims until after CMS gives the green light; resubmit claims denied because of the coding edits once the change is official; or appeal any claims denied due to the edits to the MAC, supplying supporting documentation.

    APTA regulatory affairs staff will remain in communication with CMS on the change and share new information as it becomes available.

    Comments

    • While I think this is wonderful, what's the APTA doing about the rate reduction that is slated to begin next year for the PTA? We have many people here who are losing jobs already for this and many clinics with hiring freezes for the PTA or some who are just done hiring PTAs because of all the insurance nonsense. What's being done for the PTA?

      Posted by Erynn Hanford on 1/29/2020 10:19 PM

    • Likewise, what is the APTA doing about the 15% cut to PTA payments which Medicare will apply, Humana has just announced they will apply and other payers are sure to follow? I don't even see this on the APTA's agenda.

      Posted by Cary Edgar on 1/30/2020 9:06 AM

    • @Erynn: PTAs play essential roles in the delivery of quality care for our patients and we are very disappointed that Congress established a Medicare payment differential that takes effect January 1, 2022. Unfortunately, the differential is not unusual: other essential health care providers, such as physician assistants, clinical social workers, and nurse practitioners, are paid at 85 percent of the fee schedule. This speaks to an increasingly challenging payment landscape across health care. APTA is fighting to protect payment wherever possible. For example, earlier this year we prevented CMS from devaluing care if PTAs and OTAs were furnishing care jointly with the physical therapist or occupational therapist, respectively. APTA is also advancing alternate payment models that don’t rely on a fee-for-service system to deliver care and that recognize the value of inter-and intra-professional care. If you haven’t already, check out the December blog post by David Harris, chief delegate of the PTA Caucus, in which he urges all PTs, PTAs, and students to stay involved—because the battle for quality health care and appropriate payment is ongoing. http://www.apta.org/Blogs/PTTransforms/2019/12/3/PTAPayment/

      Posted by APTA staff on 1/30/2020 11:36 AM

    • Yes I agree with Erynn and Cary. What is being done about the cuts for PTA’s. It’s looks like not enough attention is being focused on that situation.

      Posted by Octavia Spiller on 1/31/2020 1:05 AM

    • This is why we only need 2 codes. CPT 97XXX for Evaluations/Plan of Care CPT 97YYY for Physical Therapy (intervention/treatment) per 15 min.

      Posted by Russell on 2/4/2020 1:35 PM

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