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In a troubling surprise move, the U.S. Centers for Medicare & Medicaid Services announced that effective October 1, it will reverse course and reinstate previously deleted coding "edits"  for code pairs that represent common and appropriate physical therapy practice.

The return of the edits, lifted in April, run counter to best practice in physical therapy — a fact repeatedly brought to the attention of CMS and its coding contractor by APTA and other stakeholders.

Information about the reinstatement of these edits was not included in the files that were sent to health professional associations for review and comment, including APTA, offering the association no opportunity to comment on the change before it's implemented on Oct. 1. APTA has since submitted a letter to CMS and Capitol Bridge, LLC, the contractor handling the edits, requesting a halt to the reinstatement of the edits.

At issue are edits made as part of the CMS National Correct Coding Initiative that required the use of the 59 modifier or applicable X modifier to make a claim for reimbursement for many code pairings commonly used in physical therapy on the same day—for example, 97530 (therapeutic activities) and 97116 (therapeutic procedure). A strong advocacy effort by APTA members and others helped to convince CMS to reverse that decision in April. Now it appears CMS is moving ahead, providing no opportunities for input on its decision to reinstate.

The code pair prohibitions include the following: for which the edits are expected to be reinstated.

97530 with 97116
97530 with 97164
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

Pairs with an indicator of 0 are disallowed, and those with an indicator of 1 would require Modifier 59 or applicable X modifier to be appended. The full list of edits for physical therapists in private practice and facility-based providers that will take effect on October 1, 2020 are listed in excel spreadsheets found on the CMS NCCI webpage. APTA will keep members informed of the results of our efforts.

The changes are likely to have effects beyond Medicare, according to Alice Bell, PT, DPT, senior payment specialist for APTA.

"Medicare and Medicaid programs must follow these edits, of course, but the damage is far greater than that," Bell said. "Although some commercial insurers did not adopt the deletions in April those that did could also reinstate these edits. Providers should closely monitor any updates from these payers."

For more information about the National Correct Coding Initiative, please visit APTA’s NCCI webpage.

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