Update: On January 24, 2020, the APTA released a statement indicating that CMS reversed its implementation of the changes covered in this article. Learn more about this reversal here.

It feels like the term “breaking news” has lost some of its gravity these days thanks in large part to the era of the 24-hour news cycle. However, today we’re bringing you information that’s hot off the press—and absolutely crucial to every single outpatient physical therapist and occupational therapist who bills for therapeutic activities, group therapy, and manual therapy.

What happened?

As of January 1, 2020, per the National Correct Coding Initiative (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. Use of modifier 59 will not impact payment related to this change. This change will also impact athletic training evaluations and re-evaluations. Specifically, this change affects the following evaluative CPT® codes:

  • 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

Additionally, if a provider bills one of the aforementioned evaluation codes with CPT® 97140 (manual therapy) on the same date of service, then he or she must affix modifier 59 to one of the codes in order to receive reimbursement.

Download your modifier 59 decision chart.

Enter your email address below, and we’ll send you a super-simple flow chart to help you decide whether it’s appropriate to use modifier 59 in any given billing situation.

The NCCI edit chart in this blog post has been updated to reflect these changes, so feel free to use it as a reference when billing evaluations with any of the affected codes. 

Why are we finding out about this so late?

The Centers for Medicare and Medicaid Services (CMS) typically notifies the APTA of impending NCCI changes well in advance. However, according to the APTA, that was not the case this time.

Does this only impact Medicare claims?

No. This update applies to all insurance carriers that follow NCCI rules. (Please note, though, that some payers may implement these changes later than others, and there is a chance that if they do implement the changes late, they will recoup any affected payments.)

How do we know which payers use NCCI edits?

According to compliance expert Rick Gawenda of Gawenda Seminars & Consulting, you should already know: “Insurance companies that were using NCCI edits in 2019 are most likely using them in 2020,” he said in a recent call with WebPT. He added that each practice’s biller or billing company should be keeping tabs on NCCI-related denials throughout the year to ensure modifier 59 is being applied appropriately—and that the practice is receiving maximized payments. “Your billing company should be checking EOBs to see that every line item is being paid,” he said. “If it’s not, they should be looking at the denial reason code.” And if that code pertains to “mutually exclusive” services, Gawenda said, then the payer is following NCCI rules.

That being said, if you are unsure whether a particular payer adheres to NCCI edits, your best bet is to contact the payer directly to verify.

Do the new rules apply to PT and OT re-evaluations?

No. The codes for PT and OT re-evaluations (97164 and 97168, respectively) already form edit pairs with the service codes included in this update, and those edits are still in place. For example, if you billed 97164 with 97530 on the same date of service—and the two services were provided separately and independently of one another—you would affix modifier 59 to the re-evaluation code in order to receive payment for both services.

What if the evaluation was provided by a PT and the other service (e.g., therapeutic activities or group therapy) was provided by an OT?

That depends. In private practice settings where each therapist submits a separate claim under his or her individual NPI number, both the evaluation and the other service would be reimbursed. However, if the evaluation and the other service are billed under the same NPI—as is typically the case in physician-owned therapy organizations and facility-based (i.e., non-private practice) settings—then only the evaluation would be reimbursed, even if the other service was provided by a separate practitioner in a separate therapy discipline.

What can physical therapists and occupational therapists do to reverse this?

We are strongly encouraging all rehab therapy professionals to advocate on behalf of the profession. The APTA has provided this letter template, which therapists can personalize with their information and submit to Capitol Bridge, LLC, via email at NCCIPTPMUE@cms.hhs.gov. We will be advocating for the reversal of this change right alongside you, but we need every person impacted to join in and make sure all of our voices are heard.

WebPT has already updated the EMR to account for this change under all insurances that have NCCI edits applied, but we’ll keep you up to date as this situation continues to develop. For more information, CMS has provided this resource discussing this change. You can also read the APTA’s comments on the change here.