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Apparently, physical therapists (PTs), occupational therapists (OTs), and the outpatient facilities they work for aren't the only ones adjusting to the new Current Procedural Terminology (CPT) tiered coding set: recently, the Centers for Medicare and Medicaid Services (CMS) informed APTA that it's revising its National Correct Coding Initiatives “procedure to procedure” edits, a long list of CPT code pairs that should not be reported together. That list of problematic paired codes included PT and OT evaluation and reevaluation codes.

It's a complicated situation, but the bottom line is, CMS is making changes that should allow for full payment of PT and OT evaluation and reevaluations code combinations that previously resulted in erroneous payment denials or partial payment when the new code set was first adopted in January. Ironically enough, it appears the change is an attempt by CMS to correct an error in its National Correct Coding Initiative.

Here's a breakdown:

Who does this affect?
The change affects PTs, OTs, and institutions in the outpatient arena.

What was the problem?
The issue involves something called the National Correct Coding Initiative Procedure to Procedure code pair edits—an automated system that prevents improper payment when certain codes are submitted together for Part B-covered services. The problem was that this list of code sets included combinations frequently used when PTs and OTs conduct evaluations or reevaluations on the same beneficiary on the same day, a not-unusual occurrence in some outpatient facilities. When the facility or provider would attempt to seek payment using a PT/OT evaluation or reevaluation code combination, Medicare would deny the claim.

What are the code combinations in question?
The PT and OT CPT codes that were included in the list of "improper" combinations were 97161/97165, 97162/97166, 97163/97167, and 97164/97168.

Has CMS fixed it?
Mostly. APTA alerted CMS to the problem earlier in the year, and CMS issued a letter to Medicare administrative contractors to use a workaround that would allow for full payment to institutions that used the PT/OT code combinations. The workaround was a result of CMS agreeing with APTA's recommendation that the code modifier be changed from "0" to "1" for the combinations in question, a shift that tells Medicare to pay out on both codes.

What still isn't fixed is the edit table itself —that list of code combinations CMS says should not be reported together except when clinical circumstances justify it. The new version, no longer containing the PT/OT evaluation and reevaluation code combinations, is scheduled to be released July 1.

Do PTs need to do anything differently?
No. The workaround and changed modifier is allowing for proper payment at present. Once the new version of the coding edit document is released, the glitch should be completely cleaned up. Providers with questions can contact APTA advocacy staff.


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