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  • Win: CMS Backs off Changes That Got in the Way of Common Code Pairings

    Advocacy efforts by APTA and its members helped CMS and its coding contractor reverse earlier changes that complicated (and sometimes thwarted) a PT's ability to provide efficient, effective care.

    Life just got a little easier for PTs dealing with CMS National Correct Coding Initiative edits, known as NCCI edits, that prevented reimbursement for certain activity and evaluation codes when used on the same day unless a modifier was appended to the claim. In response to APTA's efforts to show how the coding changes were impacting care and complicating payment, CMS has backed off on many of the edits that were making reimbursement problematic, likely in large part due to the burden being imposed on providers by the COVID-19 public health emergency.

    The NCCI edits required the use of the 59 modifier or applicable X modifier to make a claim for reimbursement for many code pairings. APTA worked to have the edits eliminated, according to Alice Bell, PT, DPT, APTA senior payment specialist, advocating both with CMS and Capitol Bridge, CMS' NCCI coding contractors.

    However, CMS recently made changes to remove restrictions on many of the most common code pairings used in PT and PTA treatment sessions.

    The work paid off, and Bell says it's a big win for the profession.

    "These coding edits were not just problematic but actually ran counter to best practice in physical therapy," Bell said. "We're grateful to CMS and Capitol Bridge for listening to our suggestions and their willingness to consider systems that best serve patient needs."

    What Happened
    Prior to the latest change, reimbursement would be denied if, for example, code 97530 (therapeutic activities) was paired with 97116 (therapeutic procedure) without use of the 59 or applicable X modifier. The same was true for pairing 97161-97163 (physical therapy evaluations) with 97140 (manual therapy) and several other common pairings (see a complete list of edits at the bottom of this story).

    Those code pairings have been eliminated. Now PTs working in private practice and institutional settings can pair many codes without adding the 59 or applicable X modifier. Additionally, NCCI edits were lifted that prevented certain emergency department codes to be paired with physical therapy and occupational therapy evaluation and reevaluation codes. These changes are retroactive to January 1, 2020.

    The Coding Changes
    In private practice and institutional settings, PTs are now able to pair the following code combinations without the use of 59 or X modifiers:

    97530 with 97116
    97161 with 97140
    97162 with 97140
    97163 with 97140
    99281-99285 with 97161-97168
    97110 with 97164
    97112 with 97164
    97113 with 97164
    97116 with 97164
    97140 with 97164
    97150 with 97110
    97150 with 97112
    97150 with 97116
    97150 with 97164

    There are additional edit changes as well, and APTA’s National Correct Coding Initiative webpage includes a table of the common edits that remain. Check back regularly as some of these edit changes may be temporary and could be reversed after the COVID-9 public health emergency ends.

    Which Payers These NCCI Edit Changes Apply to
    Medicare and Medicaid programs follow CMS’ NCCI procedure-to-procedure edits. Additionally, most insurers also follow the NCCI PTP edits. As such, APTA recognizes that providers may receive denials on the commercial side related to these edits if they fail to use the applicable 59 or X modifier. Commercial payers may not realize the files have been updated. APTA encourages providers to use the information in this article and found on the CMS PTP Coding Edits webpage to communicate with commercial payers regarding these edit changes.


    • If I’m reading this right, you still can’t pair an evaluation with therapeutic activity code?

      Posted by Mike on 4/25/2020 11:39 AM

    • What about 97530 (therapeutic activity) paired with the evaluation codes (97161-63)? Manual therapy (97140) was already paid across payors with the evaluation codes. The biggest issue was denials for using 97530. Was this a mistake in this article?

      Posted by Patrick Toy on 4/26/2020 4:02 AM

    • Our therapist's are billing the 97530 (therapeutic activity) along with 97140 (manual) with the 59 modifier on the 97530. I would say we are at 80% of all our claims that had this scenario, the 97140 was denied. Only paying for 97530. These are two separate codes for two distinctly different procedures. Why are these codes paired together? What is the reasoning behind this?

      Posted by Lisa on 4/27/2020 12:20 PM

    • @Patrick: CMS deleted the edit prohibiting the furnishing and billing of 97530 w/ PT eval codes on the same day for the same patient in late January/early February, as discussed in these articles: http://www.apta.org/PTinMotion/News/2020/01/24/NCCIDecision/ https://www.apta.org/PTinMotion/News/2020/02/06/NCCICodeUpdate/

      Posted by APTA staff on 4/28/2020 6:37 AM

    • Need definite/clear cut answer regarding placement of modifier 59, 25 or what modifier to use when a physical therapist bills 97161 (first CPT listed) and 97530 (second CPT listed) for same date of service, and when a physical therapist bills 97161 (first CPT listed), 97530 (second CPT listed) and 19740 (third CPT listed) on the same date in order to received optimal payment for these CPTs. Sorry but there are too many voices on this subject that I am confused now.

      Posted by Bonnie on 5/3/2020 4:11 PM

    • @Bonnie: When billing 97161 and 97530 there is no modifier required. This code pair is not subject to a PTP edit. When billing 97161, 97530, and 97140 on the same date modifier 59 should be appended to CPT code 97140 as there is a PTP edit when 97140 and 97530 are billed on the same date. The edits that impacted 97161 and 97530 were deleted early this year. If a commercial payer is still requiring a modifier for this code pair please contact advocacy@apta.org so we can assist you with this issue.

      Posted by APTA staff on 5/4/2020 8:25 AM

    • Medicare is STILL denying the Eval code and 97530 even though they are saying the edits that impacted 97161 and 97530 were deleted early this year. Any suggestions on how to get these paid.

      Posted by Colleen Cleveland on 5/5/2020 12:38 PM

    • @Colleen: The problematic edits that went into effect on January 1st with the physical therapy evaluation codes have been reversed by CMS and new edit tables were issued. CMS has advised the MACs to update their files. Providers should check with their MAC to see if the claims that were denied as a result of these edits are going to be automatically reprocessed or if they need to be resubmitted or appealed. This is the text you could use in an email or phone call to communicate with the MAC regarding these edits: “On this page, CMS provides the following guidance: CMS made the decision to retain the edits that were in effect prior to January 1, 2020, and to delete January 1, 2020, PTP edits for Current Procedural Terminology (CPT) code pairs 97530 or 97150/97161, 97530 or 97150/97162, 97530 or 97150/97163, 97530 or 97150/97165, 97530 or 97150/97166, 97530 or 97150/97167, 97530 or 97150/97169, 97530 or 97150/97170, 97530 or 97150/97171, and 97530 or 97150/97172.” When submitting a claim with these code pairs for a patient covered under Medicare do not append modifier 59 or any of the “X” modifiers to the CPT codes.

      Posted by APTA staff on 5/6/2020 3:26 PM

    • So my question is with Fidelis we can use 97161 w/ 97530 with no modifier? Shouldn't we use like GP with them. Also even tho this is an evaluation with 97530 on it wont it cause the services to deny for no authorization? Even tho evals don't need authorization just the follow-ups? I just want to make sure I understand and am doing this correctly on my end

      Posted by Brittney Vivenzio -> DNW`DK on 5/7/2020 12:20 PM

    • @Brittney: The changes to the PTP edits mean that a modifier associated with the edits such as 59 or an “X” modifier is no longer required. Modifiers unrelated to the PTP edits such as the GP modifier should still be appended. This change also has no impact on prior authorization requirements. If a payer only allows an evaluation code to be billed without authorization then treatment codes should not be billed until the authorization has been provided.

      Posted by APTA staff on 5/8/2020 9:15 AM

    • BCBS Michigan is denying 97140 without modifier 59 when paired with 97162 as of May 22, 2020. Customer Service Rep, while trying to be helpful, could only offer to send back to "pricing" and allow 5 days. CSR had no idea what a CCI edit, nor modifier 59 was, nor how to advise as to how to get claim paid. This non- "solution" took 1 hour and 40 minutes. Any advice?

      Posted by Lyn on 5/27/2020 12:33 PM

    • @Lyn: Please contact advocacy@apta.org so we can assist with this issue.

      Posted by APTA staff on 5/28/2020 10:05 AM

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