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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.

    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

    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

    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