Hindsight is 20/20… this is something that comes to mind when taking a deep dive into the new and unforeseen National Correct Coding Initiative (NCCI) procedure to procedure (PTP) edits that were effective January 1, 2020.

Without any warning, Capitol Bridge, LLC, CMS’ NCCI contractor, applied two major changes that have taken the therapy community by surprise. Therapeutic activities (97530) and therapeutic procedures, group (97150) can no longer be billed on the same day as an occupational or physical therapy evaluation – 97161-97163 (PT Eval) and 97165-97167 (OT Eval). These are hard edits which means that adding a modifier 59 will not get the services paid.  Additionally, the edits are applied cross-discipline.

These edits not only prevent OT from providing therapeutic activity on the day of evaluation, but they also prevent the PT from providing therapeutic activity on the day of an OT evaluation.

Example: PT evaluates the new admit to LTC on Saturday 1/4/2020. The evaluation is billed with therapeutic exercise 97110 and gait retraining 97116; therapeutic activity 97530 is avoided due to the new edit. OT evaluates the patient on Monday 1/6/2020 and also avoids providing therapeutic activity as a part of the initial treatment. However, on Monday the PT treatment includes functional transfer training. Unfortunately, based on the NCCI PTP Edit, the PT cannot provide therapeutic activity on the same day as the OT evaluation.

CMS developed the NCCI to prevent inappropriate payment of services that should not be reported together. One function of NCCI PTP edits is to prevent payment for codes that report overlapping services except in those instances where the services are separate and distinct. In those cases, the clinician will apply a 59 modifier and attest the services are distinct and separate of one another. The documentation should also support distinctly different services.

Key Items for Provider Action:

  1. Therapist education. Not only is the use of 97530 and 97150 restricted on the same day as an OT/PT evaluation, but manual therapy 97140 now requires a 59 modifier when billed on the same date as an evaluation. Providers can review the full list of edits that went into effect January 1, on CMS PTP coding edits webpage.
  2. Therapy providers should take time to review coding definitions to ensure accurate reporting and supportive documentation of Current Procedural Terminology (CPT®) codes.

The CPT definition of 97530 is “[t]herapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes.” More detailed guidance can be found in local coverage determinations which provide that therapeutic activities are considered reasonable and necessary for patients needing a broad range of rehabilitative techniques involving movement. Movement activities can be for a specific body part or could involve the entire body. This procedure involves the use of functional activities (e.g., bending, lifting, carrying, reaching, catching and overhead activities) to improve functional performance in a progressive manner. The activities are usually directed at a loss or restriction of mobility, strength, balance, or coordination. They require the skills of a therapist and are designed to address a specific functional need of the patient.

Providers and practitioners are encouraged to send comments about the change in edits to Capitol Bridge, LLC at NCCIPTPMUE@cms.hhs.gov. Several National Associations such as NARA and APTA have issued comment letter templates to assist in making your voice heard.

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

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