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 here.

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 here.

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 here.

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.