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  • 2020 APTA Federal Advocacy Forum Will Feature Impressive Line-up; Registration Closes March 16

    APTA is gearing up for this year's APTA Federal Advocacy Forum, where members will have the opportunity to go to Capitol Hill to advocate on key legislation affecting the profession, including patient access to care, student loan forgiveness via the National Health Service Corps, prior authorization, and the proposal by Medicare to cut reimbursement to physical therapy in 2021.

    But the advocacy trip is just one part of the forum: The event also features educational sessions and opportunities to hear from speakers with important insights on political action and advocacy. This year's speaker lineup includes:

    Paul Begala. Begala, the forum's keynote speaker, is a political analyst and commentator at CNN. An affiliated professor of public policy at Georgetown University, Begala served as counselor to President Bill Clinton.

    Bradford Fitch. Monday's breakfast will feature Bradford Fitch, president and CEO of the Congressional Management Foundation, a nonprofit, nonpartisan organization that advises congressional offices on how to improve operations and advises citizens on how to improve communications to Congress. Fitch has spent 30 years in Washington as a journalist, congressional aide, consultant, college instructor, internet entrepreneur, and writer/researcher. Fitch is the author of several books, including Citizen’s Handbook to Influencing Elected Officials and Media Relations Handbook for Agencies, Associations, Nonprofits and Congress.

    Theresa Marko, PT, DPT, MS. Theresa Marko is one of the profession's most dynamic advocates. Marko is a member of APTA's Public Policy & Advocacy Committee, the American Academy of Orthopaedic Manual Physical Therapists’ Practice Committee, and the Private Practice Section's Government Affairs Committee. Marko regularly goes to the District of Columbia and her state capitol in Albany to lobby for issues important to the physical therapy profession. She has been a guest speaker on patient and physical therapist advocacy at Columbia University and LaGuardia College, and recently authored a blog post for APTA on the importance of advocacy.

    Thomas Barba, PT, MPT. An active leader and volunteer in the profession, Barba serves as Federal Affairs Liaison for the Michigan chapter of APTA, Federal Advocacy Key Contact for the APTA and the Private Practice Section, and a member of the PPS Annual Conference Program Work Group. In addition, Barba is a member of the Michigan chapter board of directors and serves on the advisory boards for Delta College PTA Program and Bay Area ISD for Health Professionals.

    Want to get a feel for what the Federal Advocacy Forum is all about? Check out the video recap of the 2019 forum on the APTA Federal Advocacy Forum webpage. And if you're in the mood for a little pre-Forum inspiration don't miss this great read from a veteran advocate Eva Norman, PT, DPT, "You Cannot Complain if You're Not Involved."

    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.

    Lawmakers Want Answers From CMS on Planned 2021 Payment Cuts

    Explain yourself: That's the message of a bipartisan letter to CMS signed by 99 members of the U.S. House of Representatives who are concerned about the agency's plan to make cuts to Medicare that include an estimated 8% reduction in payment to PTs. APTA led efforts to inform legislators of the issue.

    And if that's not enough to get CMS to take another look at the planned cut, maybe a letter from a prominent U.S. senator might help.

    In a February 5 letter, the representatives write that their constituents have concerns about whether the planned cuts will reduce access to health services. In order to respond to those concerns, the legislators are asking about the process CMS used to reach the decision to reduce the reimbursement for services furnished by certain providers in 2021 in order to accommodate increases to values of the office/outpatient evaluation and management codes, known as E/M codes.

    The letter specifically asks CMS to explain the methodology and data the agency used to calculate the estimated impact to each specialty level impact associated with the coding change, and to provide a description of the factors the agency considered in deciding how much it would reduce each of the 36 other professions selected for cuts.

    The legislators also pressed CMS on its statement that it would consider additional information before making a final decision, asking what kind of information would be of the most value, and whether CMS considered how the proposed changes could impact access to care — and if so, how.

    The letter requests that CMS respond to Congress by February 21.

    But the pressure on CMS isn't just coming from the House: Thanks to the efforts of Brenda Mahlum, DPT, the APTA Federal Affairs Liaison for the Montana Chapter, Senator John Tester (D) also sent a letter to the agency describing his concerns that the cuts "will compromise patients' access to care, particularly in the most remote areas of my state and across the country."

    "Medicare beneficiaries increasingly rely on physical therapy and occupational therapy services as part of a coordinated model of care," Tester writes, adding that the planned cuts run the risk of drying up access to care in underserved and rural areas that are already struggling to meet health care needs. "Payment decisions like the ones in this final rule will limit provision of services," Tester adds. "The physical therapists and occupational therapists in Montana operate on very narrow margins, and any reimbursement reductions may jeopardize their ability to remain open and serve their patients."

    Justin Elliott, APTA's vice president of government affairs, sees member engagement as the driving force behind the legislators' efforts.

    “We are grateful to Representatives Buddy Carter and Lisa Blunt Rochester for their leadership on this bipartisan House letter to CMS, and even more grateful to the APTA members who urged their legislators to get on board,” Elliott said. “The large number of bipartisan signatories to the letter should demonstrate to CMS that the public needs more information to understand what policy goal this flawed proposal is trying to achieve. We understand and support the desire for increased payment for the E/M codes. However, we believe it's inappropriate to reduce payment to physical therapists and 36 other provider groups as the way to pay for it.”

    Be sure to check out APTA’s resources on this issue. Ready to add your energy to APTA advocacy? Join us for the APTA Federal Advocacy Forum, March 29-31 in Washington, D.C.

    PTAs, Direct Access, Plans of Care, and More: APTA and Components Press for Changes

    If CMS really wants to put "patients over paperwork" in physical therapy, it could start by allowing PTAs to provide maintenance care across settings and easing PTA supervision requirements. And while it's at it, the agency could abandon outmoded approval requirements for plans of care, increase direct access to PTs, and expand PTs' ability to bill for care provided by a qualified substitute when the primary PT is unavailable. Those are just a few of the options that APTA and two of its components put on the table in recent comment letters.

    Ask and CMS shall receive
    The most recent comment letters — from APTA, the APTA Academy of Geriatric Physical Therapy, and the association's Home Health Section — were produced in response to a call from CMS to provide recommendations about eliminating Medicare regulations that require more stringent supervision than is required in existing state scope of practice laws, or that limit health professionals from practicing at the top of their license. CMS also asked for input on ways to strengthen its "patients over paperwork" initiative intended to ease administrative burden on health care providers as it relates to the specific areas in regulation that restrict providers from practicing to the full extent of their education and training.

    APTA took up CMS on its offer, as it typically does (in 2019 APTA submitted approximately 100 comment letters on proposed federal regulations and policies) including the most recent invitation to comment specifically on how scope of practice issues might be improved to make the system less cumbersome. As with several past calls for comment, APTA was joined by association components who have particular interest in the subject at hand. The result: multiple perspectives but a unified voice on how things could be improved.

    Opening possibilities for PTAs
    A common thread between the recommendations involved PTAs — specifically, allowing PTAs working in private practice to move to a "general supervision" model and expanding the PTA's ability to provide maintenance therapy across settings.

    Current Medicare regulations say that PTAs working in all settings except private practice may receive "general supervision" from a qualified PT, which doesn't require the PT to always be physically present. State laws can impose more stringent requirements that must be followed, of course, but the reality is that 44 states currently take the general supervision route.

    Private practice, however, is a different matter: In that setting, CMS stipulates onsite supervision, a rule that APTA believes severely limits practices and results in delays in care "that may be harmful to functional outcomes and quality of life." APTA and the geriatrics academy both press for CMS to relax the requirement.

    The letters from APTA and the Academy of Geriatric Physical Therapy also push for an expanded role for PTAs related to maintenance therapy under Medicare Part B. Right now, PTAs may furnish skilled maintenance therapy in skilled nursing facilities — SNFs — and home health settings under Medicare Part A only, and they are prohibited from providing maintenance therapy in private practice settings. the submitted letters assert that PTs are perfectly capable of making a determination as to whether it's clinically appropriate for a PTA to provide maintenance therapy, and that leveling the requirements "would provide regulatory alignment and afford providers more latitude in resource utilization."

    Getting real with plans of care and direct access
    PTAs weren't the only focus of the letters: Clunky provisions around whether and how PTs create plans of care and needless limits on direct access to PT services both received attention from APTA and the two components in various combinations.

    Both APTA and the Home Health Section argued for changes that would allow PTs to establish home health physical therapy plans of care, as they are allowed to do in outpatient settings. In its letter, the Home Health Section writes that PTs "are unnecessarily burdened by asking physicians to establish and review therapy plans of care in home health, and physicians are unnecessarily burdened by establishing and reviewing those same plans of care."

    Another provision that prevents PTs from practicing at the top of their license, according to APTA and the Academy of Geriatrics Physical Therapy: so-called "certification requirements" for plans of care that gum up care delivery. Under current rules, outpatient plans of care for therapy must be accompanied by a physician or qualified nonphysician practitioner signature, a requirement that frequently leads to delays in providing needed therapy while the PT waits for (and sometimes repeatedly reminds) the physician to sign off.

    Both letters describe the certification requirement as an "untenable" administrative burden for PTs, with APTA writing that "[PTs] and other therapy providers should not be held responsible and possibly subject to medical review due to a physician's inaction."

    Both letters also express that it's high time for CMS to extend direct access to PTs in hospitals, including critical-access hospitals, and SNFs.

    "Medicare beneficiaries [in these settings] who require rehabilitation frequently are admitted to a hospital but then must 'sit and wait' until a practitioner can sign an order," APTA writes. "While hospitals are showing a statistically significant decrease in specific health care-associated infections, the evidence regarding hospital-associated disability is mounting, clearly indicating the medical necessity of early and progressive mobilization during the acute period of the episode of care."

    These dangers could be avoided, both letters argue, if CMS would permit stronger direct access provisions in these settings, with the letter from the Academy of Geriatric Physical Therapy stating that "direct access increases choice in the selection of a health care professional, offers access to less expensive and more timely care, and is a simple yet extremely effective way to meet the goals of increased access and cost containment."

    Expanding locum tenens
    While it's technically true that CMS affords PTs locum tenens — the provision that allows a provider to retain a substitute when she or he is absent because of illness, vacation, pregnancy, or continuing education and still receive payment — the allowance is currently limited to specific geographic areas that have been identified as having gaps or shortages in health care. In its letter, APTA urges CMS to work with Congress to change language in the 21st Century Cures Act to extend locum tenens to all qualified PTs regardless of geographic location.

    Also on the list
    Alone or in combination, the letters recommend a number of other changes including allowing PTs working in the home health and SNF settings to make "insignificant" changes to plans of care without being required to notify the physician (in the event that CMS doesn't adopt the larger plan-of-care suggestions), standardizing data submission, removal of certain data collection requirements and standardizing others, and prohibiting Medicare Administrative Contractors from requiring a physician order for PTs to furnish wound care.

    APTA regulatory affairs staff is in regular contact with CMS staff and will continue to press for needed changes and share information as it becomes available.

    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.

    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.

    What's Happening at the State Level: Hot Issues for 2020

    It's that time: Across the country, most state legislatures are either back in session or headed that way. And again this year, issues important to PTs, PTAs, and the patients they serve are on the radar in many statehouses.

    In preparation for what promises to be another busy year, we've put together a list of some of the issues that will get attention from lawmakers in the coming weeks and months. Take a look at what's coming — and then don't forget to help press for needed change by contacting your APTA chapter and the national office to sign up for action alerts, and see how you can get involved. (And check out APTA's State Advocacy webpage.)

    Direct Access
    States with potential legislation in 2020: Alabama, Kansas, Minnesota, Mississippi, Missouri, New York,  South Carolina, Tennessee

    Background: Improving direct access to physical therapy, ideally without a physician referral, is a longstanding priority for the association and its chapters. And we've made progress: All states now have some form of direct access, but some forms are more limited than others, imposing restraints such as referral requirements and visit limits for specific interventions. Legislative energy is now being devoted to improving these more restrictive systems, bolstered by a recent APTA consponsored study that found unrestricted direct access to physical therapy for low back pain saves money and lowers utilization of services overall.

    Resources: Direct Access at the State Level webpage

    Telehealth
    States with potential legislation in 2020: Arizona, Georgia, Rhode Island

    Background: Telehealth provisions for PTs are explicitly included in laws and/or regulations in 16 states, with nine states allowing Medicaid reimbursement for telerehab and 11 more including language that opens up that possibility. The U.S. Department of Veterans Affairs allows PTs to engage in telehealth, to successful results. The states listed above want to add telehealth the PT scope of practice, allow for Medicaid reimbursement for telehealth delivered by PTs, or both.

    Resources: Telehealth webpage

    Physical Therapy Compact
    States with potential legislation in 2020: District of Columbia, Massachusetts, Michigan, Ohio, Pennsylvania, Rhode Island, South Dakota, Vermont, Wisconsin

    Background: The system that allows PTs and PTAs licensed in one compact state to obtain practice privileges in other compact states grew to include 26 states in 2019, with five more — Arkansas, Delaware, Georgia, Maryland, and Virginia — having adopted the legislation in advance of enactment. Widespread participation in the compact is a professional game-changer, particularly as PTs' and PTAs’ ability to participate in telehealth grows.

    Resources: Physical Therapy Licensure Compact webpage

    Dry Needling
    States with potential legislation in 2020: California, Connecticut (pending a court ruling), Hawaii, New Jersey (held over from 2019)

    Background: Currently, 35 states and the District of Columbia allow PTs to perform dry needling, seven states prohibit it, and eight states are silent on the issue. Chapters from the states listed above are looking to add a specific mention of dry needling to their PT practice acts.

    Resources: Dry Needling in Physical Therapy webpage

    Fair Copays
    States with potential legislation in 2020: Georgia, New York, Ohio, Rhode Island, Virginia

    Background: Like direct access, the issue of fair copays has been a central advocacy focus for some time at both the state and federal levels. Many insurance provisions classify PTs as specialists and impose higher copays; it's an approach that ignores the fact that physical therapy often requires multiple visits, making seeing a PT cost prohibitive. APTA and its chapters want to change that by, at the very least, following a lead established in Kentucky in 2011 that limits physical therapy copays to no more than the copay for a visit to a primary care provider.

    Resources: Fair Physical Therapy Copays webpage

    Imaging
    States with potential legislation in 2020: Connecticut, Illinois, Rhode Island

    Background: The importance of PTs to achieve practice authority for ordering and performing appropriate imaging studies was underscored by the APTA House of Delegates in 2016, when it directed the association to press for changes to imaging restrictions. Currently, only Colorado, Wisconsin, and Utah expressly allow PTs to order imaging under certain conditions.

    Resources: Imaging webpage

    Utilization Management
    States with potential legislation in 2020: Oregon

    Background: Used properly, utilization management can help PTs provide patient-centered and timely care to patients; too often, however, it serves as little more than a barrier to needed care and an excessive administrative burden for providers. States are looking for ways to better regulate the practice so that it doesn't get in the way of patient access to needed services.

    Resources: APTA Utilization Management Toolkit

    Practice Act Updates
    States with potential legislation in 2020: Alaska, Florida, Tennessee

    Background: Times change, and so do concepts of legal scopes of practice for PTs and scopes of work for PTAs. A large-scale revision of a state's PT and PTA regulatory language can be a major undertaking, but chapters regularly step forward to take on the challenge and ensure that PTs in their states are practicing under laws that aren't antiques.

    Resources: Jurisdictional Scope of PT Practice webpage

    APTA's Physical Therapy Outcomes Registry Again Receives QCDR Designation for MIPS Reporting, Adds New Measures

    APTA's Physical Therapy Outcomes Registry has been approved for the fourth year in a row by the U.S. Centers for Medicare and Medicaid Services as a qualified clinical data registry, or QCDR. This designation means that participating physical therapists can submit Merit-based Incentive Payment System — MIPS — reporting data to CMS directly from the registry. QCDR approval recognizes APTA's demonstrated expertise in quality measure development.

    The Physical Therapy Outcomes Registry supports 19 Quality Payment Program measures, 11 QCDR measures, and two electronic clinical quality measures. CMS requires that the electronic clinical quality measures must be reported using certified electronic health record technology, also known as CEHRT.

    As of January 2019, PTs who provide services under Medicare Part B who meet qualifying criteria must participate in either MIPS or an Advanced Alternative Payment Model (Advanced APM). PTs who participate in the Registry can meet MIPS requirements in both the Quality and Improvement Activities categories. Submitting data via a QCDR also earns "bonus" points in the Promoting Interoperability category, which is not yet required for PTs.

    Whether or not PTs participate in MIPS, according to Heather Smith, PT, MPH, APTA's director of quality, APTA’s registry is a valuable tool for optimizing patient outcomes.

    "Participants have found that registry data has opened their eyes to areas for improvement, and even informed changes to the way they deliver care," Smith said. "Registry analytics allow therapists to objectively understand how their practice patterns and interventions are impacting patient outcomes."

    Registry users can access nonproprietary outcomes measures supported by CMS, as well as specific measures shared from other QCDRs.

    By directly integrating with EHRs, the registry enables PTs — whether or not they participate in MIPS — to leverage their existing EHR data to track and benchmark outcomes, apply dashboard insights to improve quality of care, and demonstrate the value of physical therapist services to payers and providers. For more information about the Physical Therapy Outcomes Registry, visit www.ptoutcomes.com.

    Headed to the APTA Combined Sections Meeting in February? Visit the APTA Pavilion in the Exhibit Hall to learn more about how the registry can benefit your practice. Related education sessions include "Demonstrating Value: Using Clinical Data and Databases to Improve Outcomes for Patients and the Population" and "Through the Looking Glass: What Are the Emerging Payment and Quality Issues?"

    2020 Federal Advocacy Forum Coming March 29; Registration Open Through March 16

    While 2019 saw some real advocacy achievements for the physical therapy profession, the year also brought challenges to tackle in 2020 — not the least of which is the proposal by Medicare to cut reimbursement to physical therapy in 2021. And with APTA's fight against the cut already in motion, the 2020 Federal Advocacy Forum, set for March 29-31, couldn't come at a better time.

    Registration is now open for the annual event, which brings PTs, PTAs, and students together in Washington, DC, for a three-day conference that provides the latest on regulatory and legislative issues affecting the profession, and ends with an opportunity for attendees to apply what they've learned by making in-person visits to Senate and House offices. Registration deadline is March 16.

    The forum's keynote speaker will be Paul Begala, political analyst and commentator at CNN. An affiliated professor of public policy at Georgetown University, Begala served as counselor to President Bill Clinton.

    Begala's participation is in keeping with the forum's tradition of offering a variety of speakers with diverse perspectives. Past keynote speakers include political commentator Fred Barnes, FOX News host Tucker Carlson, and political strategist Donna Brazile.

    Other forum activities will include an evening reception and breakout sessions on advocacy-related topics.

    "The proposed 8% cut will be one of the issues the profession will share with their elected officials, and APTA will continue to educate Congress about the essential role that physical therapists play in the delivery of quality health care for patients of all ages across the country," said Michael Matlack, APTA's director of congressional affairs. "Now, more than ever, the voice of the physical therapy profession is critical to the health and well-being of our patients and our industry. "

    Want to get a feel for what the Federal Advocacy Forum is all about? Check out the video recap of the 2019 forum on the Federal Advocacy Forum webpage.

    NCCI Code Edits: Your Questions Answered

    Background: A surprise coding change issued by the Centers for Medicare and Medicaid Services (CMS) caused an uproar in the physical therapy community earlier in January, and for good reason: The new requirements state that CMS won't reimburse for certain activity and evaluation codes if they're used in the same day. APTA argues that accepted physical therapist practice often includes the startup of care on the same day as evaluation (and continued care on the same day as reevaluation), and that the prohibition runs counter to CMS' own aims for care.

    Reaction: Since the announcement, Capitol Bridge, LLC, CMS' National Correct Coding Initiative (NCCI) contractor, has been inundated with comments from PTs, PTAs, and other stakeholders slamming the decision and requesting that the change be reversed. And it's not too late to add your voice to the effort. APTA is communicating with representatives from Capitol Bridge, CMS, and the American Medical Association, which plays a significant role in coding development.

    Where things stand: As of the date of this report, no changes have been made. That leaves PTs and PTAs to deal with the current prohibition, as problematic as it may be.

    To help you navigate the system as it is, here are answers to some of the most common questions we've been receiving on the NCCI coding change.

    1. What are NCCI Procedure-to-Procedure (PTP) code pair edits?
    NCCI PTP edits are intended to prevent payment of services that should not be reported together. Each edit has a Column One and Column Two Health Care Common Procedure/Current Procedural Terminology (HCPCS/CPT) code, called a “pair.” If a provider reports the two codes of a pair for the same beneficiary on the same date of service, only the Column One code is eligible for payment; the Column Two code is denied unless a clinically appropriate NCCI-associated modifier is also reported.

    As for modifiers, each PTP edit has a modifier indicator, represented by (0), (1), and (9), that appears after the code number. Here's what those numbers mean:

    • 0 - There are no circumstances in which a modifier would be appropriate. The services represented by the code combination will not be paid separately.
    • 1 - A modifier is allowed in order to differentiate between the services provided. Assuming the modifier is used correctly and appropriately, this distinction provides the basis upon which separate payment for the services billed may be considered justifiable.
    • 9 – The deletion date of the code pair is the same as the effective date. In other words, these edits are no longer active, so the code combinations are billable, and no other modifier is needed.

    2. What happens if I bill 97530 (therapeutic activities) and 97161, 97162, or 97163 (physical therapy evaluations) together on same day for same patient?
    This is at the heart of the recent edit. Under the new rules, the use of both codes is prohibited, and there's no modifier that you can use to bypass the denial. That includes the 59 modifier/X modifier: You can't use the 59 modifier/X modifier when billing 97530 with 97161, 97162, or 97163 to bypass the edit.

    Bottom line: when 97530 and one of the physical therapy evaluation codes are billed together on the same day for the same patient, the evaluation code will be denied. This is because in the PTP edits list, 97530 is the Column One code and 97161, 97162, and 97163 are Column Two codes (see the answer to question 1 for more background on Column One and Column Two codes).

    3. Why is 97530 (therapeutic activities) in Column One and 97161-97163 (physical therapy evaluations) in Column 2?
    Good question. We believe this PTP edit is inconsistent with the general guidelines for PTP edits, and it's one of the reasons APTA and other stakeholders are working with CMS to have this edit removed as soon as possible.

    4. What happens if I bill 97150 (group therapy) and 97161, 97162, or 97163 (physical therapy evaluations) together on the same day for same patient?
    As with the therapeutic activities code covered in question 2, the answer is, you won't get reimbursed for the evaluation — and there is no modifier you can use to bypass the edit, including the 59 modifier/X modifier. This is because in the PTP edits list, 97150 is the Column One code and 97161, 97162, and 97163 are Column Two codes. Under the policy, when Column One and Column Two codes are billed, the Column One code is eligible for payment and the Column Two code is denied.

    5. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97140 (manual therapy) and 97161-97163 (physical therapy evaluation codes)?
    Yes. It's possible to bypass the edit by using the 59 modifier/X modifier when billing 97140 with the physical therapy evaluation codes (97161, 97162, or 97163). If you don't use the modifier for this combination of codes, CMS will deny the manual therapy code. This is because in the PTP edits list, 97161-97163 is the Column One code and 97140 is the Column Two code. Under the policy, when Column One and Column Two codes are billed, the Column One code is eligible for payment and the Column Two code is denied — unless an appropriate modifier is used.

    6. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97530 (therapeutic activities) and 97164 (physical therapy re-evaluation)?
    Yes, you are permitted to bill 97530 with 97164 if you use the 59 modifier/X modifier. If you do not bill with the appropriate modifier, then 97164 (Column Two code) will be denied. (See question 5).

    7. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97150 (group therapy) and 97164 (physical therapy re-evaluation)?
    Yes, for the same reason explained in questions 5 and 6.

    8. Do PTP edits apply across disciplines?
    Unfortunately yes, when services are billed under the same provider number. For example, if the occupational therapist performs 97530 on the same day as the PT who bills an evaluation code, the evaluation code will be denied if the services of both providers are billed under the same provider number (as in institutional billing).

    9. What settings do PTP code pair edits apply to?
    The NCCI edits consist of two provider-type choices of PTP code pair edits: practitioners and hospitals.

    By "practitioners," CMS means that the NCCI edits apply to claims submitted by physicians, nonphysician practitioners, and ambulatory surgical centers. This includes PT private practitioners.

    The definition of "hospital," for purposes of this edit, extends to outpatient hospital services and other facility services including, but not limited to, therapy providers in Part B skilled nursing facilities, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech-language pathology providers, and home health agencies for certain claims billed under Type of Bill (TOB) 22X, 23X, 75X, 74X, 34X.

    10. Do NCCI edits apply to all third-party payers?
    Yes and no. Technically, the NCCI edits only apply to Medicare fee-for-service, but the majority of commercial payers do use the NCCI edits in their systems, so there's a good chance you'll need to comply with the edits even if you aren't working with Medicare. Some workers compensation programs and self-insured plans may create their own edits.

    11. Are there other edits I should be aware of?
    Yes, there are many PTP edits for hospital and practitioner settings. The PTP edits are updated on a quarterly basis. To stay up to date, visit the CMS PTP Coding Edits page, scroll down to related links, and click on the appropriate setting link (Hospital PTP edit or Practitioner PTP edit) for the relevant time period.

    12. What happens next?
    APTA continues to pressure CMS to remove these edits. CMS has met with the NCCI contractor to discuss the edits and is working on a resolution. We hope to have additional information to share in the near future.

    Looking for additional information about NCCI edits? Visit the National Correct Coding Initiative Edits webpage or contact APTA at advocacy@apta.org.