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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.

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