CMS loves to shake things up—especially when it comes to NCCI edit pairs and modifier 59. In fact, last year, CMS published four significant updates to its NCCI edit pairs—all of which impacted rehab therapists. And in January of this year, CMS was back at it again, deleting edit pairs and making retroactive changes that, while beneficial to rehab therapists, are still liable to create a paperwork pileup.
Not sure what those changes are? No worries—let’s walk through them together.
CMS added some NCCI edit pairs and deleted others retroactive to December 31, 2019.
For the most part, CMS didn’t add any new CCI edit pairs that were relevant to PTs and OTs this year—though SLPs saw some updates to their CPT code repertoire. The pairs in the following table were added as of January 1, 2021.
| Column 1 | Description | Column 2 (y=use modifier 59; n=do not bill in combination with code from Column 1 |
| 92526 | Treatment of Swallowing Dysfunction | 69705y; 69706y |
| 92610 | Evaluation of Swallowing | 69705y; 69706y |
| 92611 | Modified Swallow Study | 69705y; 69706y |
| 92612 | Flexible Endoscopic Eval of Swallowing | 69705y; 69706y |
| 92614 | Flexible Endoscopic Evaluation; Laryngeal Sensory Testing by Cine or Video Recording | 69705y; 69706y |
| 92616 | Flexible Endoscopic Evaluation of Swallowing and Laryngeal Sensory Testing by Cine or Video Recording | 69705y; 69706y |
In addition to introducing some new NCCI edit pairs, CMS deleted many previous pairs that were relevant to PTs and OTs. This is a big win, as many of the deleted edit pairs are commonly billed together. The pairs in the following table were deleted retroactive to December 31, 2019, unless otherwise indicated.
| Column 1 | Description | Column 2 (y=use modifier 59; n=do not bill in combination with code from Column 1 |
| 97110 | Therapeutic Exercises | 97164y; 97168y |
| 97112 | Neuromuscular Re-Education | 97164y; 97168y |
| 97113 | Aquatic Therapy/Exercise | 97164y; 97168y |
| 97116 | Gait Training | 97164y; 97168y |
| 97140 | Manual Therapy | 97164y; 97168y; 97530y |
| 97150 | Group Therapy | 97164y; 97168y |
| 97161* | PT Evaluation: Low Complexity | 97140y |
| 97162* | PT Evaluation: Moderate Complexity | 97140y |
| 97163* | PT Evaluation: High Complexity | 97140y |
| 97165* | OT Evaluation: Low Complexity | 97140y |
| 97166* | OT Evaluation: ModerateComplexity | 97140y |
| 97167* | OT Evaluation: High Complexity | 97140y |
| 97530 | Therapeutic Activities | 97113y; 97116y; 97164y; 97168y |
* = Deleted retroactive to January 1, 2020.
Most commercial payers have yet to enact these changes.
While CMS has committed to these NCCI edit changes for 2021, many commercial payers have yet to follow suit. Most commercial payers do typically adopt CMS’s edit updates, but it can take some time for them to apply the changes—and they may not be retroactive. However, it sounds like commercial payers are moving in the right direction. Per the APTA, Cigna committed to applying the aforementioned changes in mid-February—though it declined to apply these changes retroactively.
Contact your MAC to learn how to reprocess previously denied claims—and check in with your commercial payers, too.
It’s not yet clear how therapists should tackle the task of reprocessing previously denied claims. Your best bet is to reach out to your local Medicare Administrative Contractor (MAC) and inquire about what protocol to follow. The same goes for your commercial payers. As they start aligning their policies to match Medicare’s (and if they apply these edits retroactively), you’ll need to confirm how you can efficiently reprocess any affected claims.
And that about covers it! Those are the January 2021 NCCI updates that affect PTs, OTs, and SLPs. Got any questions? Feel free to leave a comment below, and our team will do its best to help you out.
