It appears 2020 has a few more tricks up its sleeve for physical therapists and occupational therapists. According to an announcement from the Centers for Medicare and Medicaid Services (CMS), the agency has decided to reinstate changes to National Correct Coding Initiative (NCCI) edit pairs that are frequently used by rehab therapists. The changes—originally implemented in January and catching many rehab therapy providers off guard—were later removed, signifying to many that they were implemented in error.
If you’re unfamiliar with the saga behind these changes, here a brief recap:
January 1, 2020 Changes
As of January 1, 2020, per the NCCI, “when PTs and OTs bill an initial evaluation along with CPT® code 97530 (therapeutic activities) and/or 97150 (group therapy)—on the same date of service and for the same patient—they will only receive payment for the evaluation.” Using the 59 modifier would not have impacted any payments related to this change. Furthermore, this extended to athletic training evals and re-evals.
This change also required providers to affix modifier 59 when billing any of the aforementioned eval codes—as well as many other codes commonly used by PTs and OTs—with CPT® 97140 (manual therapy) on the same date of service.
Read our full post on these changes.
January 24, 2020 Update
On January 24, 2020, the APTA announced the reversal of the January 1 ruling. This meant that moving forward, PTs, OTs, and ATCs could resume billing most of the above-mentioned codes just as they did in 2019 and receive reimbursement (if applicable). This reversal was applied retroactively, starting with any relevant claims dated January 1, 2020, and CMS stated that providers would be able to recoup any payments lost as a direct result of the initial change.
That said, as of the January 24 update, the changes involving CPT® code 97140 (manual therapy) were still in effect.
Read our full post on this update.
April 21, 2020 Update
Finally, in April, the remaining NCCI changes were reversed, which meant therapists would no longer need to affix modifier 59 when billing 97140 with eval codes and other commonly-used CPT® codes (e.g., 97530 [therapeutic activities] and 97116 [therapeutic procedure]) on the same date of service. This change impacted all Medicare and Medicaid programs and was retroactive to January 1, 2020.
Read our full post on this update.
October 1, 2020 Reversal
Back to the present day: CMS has announced that the April 21 ruling will be reversed effective October 1, 2020. According to the APTA, “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.”
Now for some good news: It appears that many of the added pairs will be eligible for modifier 59 use, which means therapists will still be able to obtain reimbursement for both services when they are provided separately and independently of one another on the same date of service. Here are the highlights, according to our billing experts at WebPT:
- The PT evaluation codes (97161–97163) and OT evaluation codes (97165–97167) are:
- edited against (i.e., form edit pairs with) the code for manual therapy techniques (97140), but can be billed with modifier 59; and
- also edited against codes 97750, 97755, 97763 as mutually exclusive and cannot be billed with a modifier.
- The PT re-evaluation code (97164) and OT re-evaluation code (97168) are:
- edited against 97750, 97755, 97763 as mutually exclusive and cannot be billed with a modifier.
And here’s the full list of updated edits for rehab therapy codes. If a code in Column 2 is followed by “y,” it can be billed with modifier 59 in combination with the code in Column 1. If a code in Column 2 is followed by “n,” it should not be billed in combination with the code in Column 1, as it will not be paid.
| Column 1 | Column 2 (y=use modifier 59; n=do not bill in combination with code from Column 1) |
| 97012 | 97164y, 97168y |
| 97016 | 97164y, 97168y |
| 97018 | 97164y, 97168y |
| 97022 | 97164y, 97168y |
| 97024 | 97164y, 97168y |
| 97026 | 97164y, 97168y |
| 97028 | 97164y, 97168y |
| 97032 | 97164y, 97168y |
| 97033 | 97164y, 97168y |
| 97034 | 97164y, 97168y |
| 97035 | 97164y, 97168y |
| 97036 | 97164y, 97168y |
| 97039 | 97164y, 97168y |
| 97110 | 97164y, 97168y |
| 97113 | 97110y, 97164y, 97168y |
| 97116 | 97164y, 97168y |
| 97124 | 97164y, 97168y |
| 97129 | 97164y, 97168y |
| 97130 | 97164y, 97168y |
| 97139 | 97164y, 97168y |
| 97140 | 97164y, 97168y, 97750y |
| 97150 | 97110y, 97112y, 97116y, 97164y, 97168y, 97535y, 97760y, 97761y |
| 97161 | 97140y, 97164n, 97750n, 97755n, 97763n |
| 97162 | 97140y, 97161n, 97164n, 97750n, 97755n, 97763n |
| 97163 | 97140y, 97161n, 97162n, 97164n, 97750n, 97755n, 97763n |
| 97164 | 97750n, 97755n, 97763n |
| 97165 | 97140y, 97168n, 97750n, 97755n, 97763n |
| 97166 | 97140y, 97165n, 97168n, 97750n, 97755n, 97763n |
| 97167 | 97140y, 97165n, 97166n, 97168n, 97750n, 97755n, 97763n |
| 97168 | 97750n, 97755n, 97763n |
| 97530 | 97116y, 97164y, 97168y, 97535y, 97750y |
| 97533 | 97164y, 97168y |
| 97535 | 97164y, 97168y |
| 97537 | 97164y, 97168y |
| 97542 | 97164y, 97168y |
| 97545 | 97164y, 97168y |
| 97597 | 97164y |
| 97598 | 97164y |
| 97602 | 97164y |
| 97605 | 97164y |
| 97606 | 97164y |
| 97607 | 97164y |
| 97608 | 97164y |
| 97750 | 95851n, 95852n, 97150n |
| 97755 | 97035y, 97110y, 97112y, 97140y, 97530y, 97533y, 97535y, 97537y, 97542y, 97545y, 97750n, 97760y, 97761y, 97763y |
| 97760 | 97016y, 97110y, 97112y, 97116y, 97124y, 97140y, 97164y, 97168y, 97763n |
| 97761 | 97016y, 97110y, 97112y, 97116y, 97124y, 97140y, 97164y, 97168y, 97760y, 97763n |
| 97763 | 97110y, 97112y, 97116y |
APTA has requested that CMS and Capitol Bridge, LLC, halt this reinstatement.
To learn more about these and other edits that will go into effect October 1, refer to this spreadsheet on the CMS website.
Stay tuned to the WebPT Blog and the APTA website for more updates on this reversal as the situation develops.
