The therapy industry recently received some good news in terms of hard edits that were previously applied effective January 1, 2020 without warning. Our blog posted on 1/16/2020 shared that therapeutic activities (97530) and group therapy (97150) could no longer be billed on the same day as an occupational or physical therapy evaluation – 97161-97163 (PT Eval) and 97165-97167 (OT Eval). In response to comments received from stakeholders, CMS decided to retain the CCI edits that were in effect prior 2020. The edit correct will be retroactive from dates of service beginning January 1, 2020.

The 2020 version of the National Correct Coding Initiative (NCCI) Policy Manual for Medicare Services has been updated and posted on the National Correct Coding Initiative (CCI) webpage of the CMS website. While the use of 97530 and 97150 is no longer restricted with a hard edit on the same day as an OT/PT evaluation, the Modifier 59 will need to be applied when furnishing therapeutic activity 97530, group therapy 97150, or manual therapy 97140 on the same date as the evaluation. CMS clarifies proper use of Modifer 59 in this MLN article (see example 9).

Though CMS has notified MACs, providers should keep a close watch for any denied claims due to the PTP edits and contact with their MAC about claim adjustments required with this January 1, 2020 retroactive date.



Blog by Stacy Baker, OTR/L, RAC-CT, CHC, Proactive Medical Review

Learn more about Stacy and the rest of the Proactive team.