Earlier this month, we covered some major changes to the NCCI edit rules set forth by the Centers for Medicare and Medicaid Services (CMS). Per those changes, as of January 1, 2020, PTs, OTs, and ATCs were no longer receiving payment on the following CPT codes when billed with CPT® code 97530 (therapeutic activities) and/or 97150 (group therapy):
- 97161: PT evaluation – low complexity
- 97162: PT evaluation – moderate complexity
- 97163: PT evaluation – high complexity
- 97165: OT evaluation – low complexity
- 97166: OT evaluation – moderate complexity
- 97167: OT evaluation – high complexity
- 97169: Athletic training evaluation – low complexity
- 97170: Athletic training evaluation – moderate complexity
- 97171: Athletic training evaluation – high complexity
- 97172: Athletic training re-evaluation
Today, however, the American Physical Therapy Association (APTA) announced the reversal of this ruling, which means that moving forward, PTs, OTs, and ATCs can continue billing these codes together—just as they did in 2019—and they will receive reimbursement when applicable. Furthermore, in a recent statement to the APTA, CMS confirmed this change will be retroactive starting with claims dated January 1, 2020. The statement also noted that therapists will be able to recoup any denied payments related to the original policy. According to this APTA resource, CMS has notified Medicare Administrative Contractors (MACs) of this protocol, although providers should still check with their individual contractor first before resubmitting or appealing denied claims.
Additionally, the APTA announcement indicates that the January 1 change involving CPT® code 97140 (manual therapy) still stands. This change required providers to affix the 59 modifier to the claim when billing 97140 with any of the evaluation codes listed above (provided that the services were provided separately and independently of one another). So, we recommend providers continue using the 59 modifier in this circumstance.
For more information on this rule reversal, check out this article from the APTA.