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  • CMS Coding Reversal Update: Providers Can Start Checking in With MACs

    It's official: Medicare Administrative Contractors for CMS have been notified of the agency's decision to reverse coding methodology decisions that prevented PTs from billing an evaluation and therapeutic activities or group therapy activity delivered on the same day, and to apply that decision to claims made back to the beginning of the year. The announcement means that providers can begin resubmitting or appealing claims that were denied while the now-defunct system was in place — but the contractor responsible for coding implementation says to check with your Medicare Administrative Contractor first.

    In a February 5 communication to APTA, Capitol Bridge LLC stated that CMS had "instructed the Medicare Administrative Contractors [known as MACs] to implement the replacement edit files and make claim adjustments," and announced that those replacement files are now available on both the Medicare Procedure-to-Procedure coding updates webpage and the Medicaid National Correct Coding Initiative Edit Files webpage. Capitol Bridge is the CMS contractor for the National Correct Coding Initiative, or NCCI.

    "Providers may check with their MAC about claim adjustments, appeal claims denied due to the [Procedure-to-Procedure, or PTP] edits to the appropriate MAC, or resubmit claims due to the PTP edits after implementation of the replacement edit file with January 1, 2020, retroactive date, as permitted by the MAC," Capitol Bridge writes. It advises providers to contact their MAC with questions about individual claims.

    APTA regulatory affairs staff will remain in communication with CMS and the NCCI contractor on the change and will share any new information that becomes available. For additional information, visit APTA’s webpage on the NCCI.


    • Thank you for the opportunity to express concern regarding the new 2020 physical therapy edit where 97140 (Manual Therapy) is edited with the initial evaluation. Especially in the outpatient private practice setting, this edit puts a significant hardship on the patient, provider, and ultimately the Medicare system. For example, I had several new patients this week alone who needed little more than manual therapy services yet because we are not allowed to perform an initial evaluation on the same day as the manual therapy service, I had to make the decision to either apply the -59 modifier or strain the Medicare system by having the patient return for a follow-up visit (which may or may not have been necessary had I been able to perform the manual techniques immediately). Medicare has specifically advised the -59 modifier should "not be used routinely". Details of these patient encounters may be helpful: After completing the initial history and physical examination (which took approximately 12 minutes on each of these patients), the following was discovered: Patient #1. Sustained a Sacral Torsion from a fall off of her bed two days prior. The standard care for this injury is to apply principles of manual medicine via MET which typically immediately corrects the torsion and full function returns. Practicing physical therapy for nearly 30 years, I can attest that probably 25% of these patients call to cancel their follow up visit because their function is fully restored and pain is manageable with ice at home. (no need to bill Medicare a second visit). When you wait too long to correct, muscle memory engages and the problem becomes much more difficult to manage (with sometimes a lengthy plan of care resulting). Patient #2. Patient picked up a case of water bottles at Costco, twisted to put it into the trunk of car and sustained a vertebral segment rotation. Subsequent muscle spasm resulted and he was miserable during initial evaluation. The standard of care would be to offer soft tissue mobilization to break intrinsic muscle spasm cycle, then immediately implement MET strategies to correct the segment. typically spasm resolves almost instantly. It's great actually. However....with the edited codes, instead I chose to try to do range of motion and stretching activity and scheduled him for our next available appointment which is not until Monday. That's 3+ more days of spasm due to segment rotation. Who knows what we will see Monday when we could have possibly had him corrected and on ice for the weekend (and hopefully not even have the need for a followup visit) Patient #3 2 weeks + 2 days post surgical TKA (total knee replacement). His leg was so swollen that I could not get a distal pulse. I elected to do the 97140 work, even though it was edited with my evaluation. I did apply the -59 modifier. After extensive retrograde work to increase fluid exchange, decrease capillary hyrdostatic pressure, and move the edema, I was able to palpate both posterior tibial AND dorsalis pedis pulses. I then essentially wrote a dissertation to support the use of the -59 modifier (& I worried about this all night). Patient #4 presented with a Grade II+ hamstring strain. The orthopedic surgeon sent him over immediately for physical therapy services because the patient has a history of blood clots, and the fact that the thigh was very swollen, dense, ecchymotic and painful. This patient could not tolerate stretching yet (stretching could actually be more harmful than helpful since injury occurred just 5 days ago). this patient needed manual therapy work to reduce the 6" softball size hearty knot more than anything. The standard of care would be to start with manual services right away. With patient #4 as example, I would have to do the evaluation (less than 15 minutes), send him home, and wait for him to return for our next available appointment. It would be concerning that a blood clot could develop, or worse, which would cost the Medicare system significantly more than just treating him on the same day as the evaluation. I am hopeful these specific examples are helpful to explain why it is imperative that we please reverse this edit as soon as possible. The treatment they all needed was manual therapy. This is truly the standard of practice for orthopedic physical therapy. So many physical therapy patients, especially in the outpatient private practice setting, show up just as these four patients did, all in just one day. They need our Manual Therapy skills. With utmost sincerity, on behalf of all private practice outpatient physical therapists, I respectfully request this this edit be reconsidered and reversed as soon as possible.

      Posted by SANDRA L KLASSEN on 2/13/2020 3:12 PM

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