Background: A surprise coding change issued by the Centers for Medicare and Medicaid Services (CMS) caused an uproar in the physical therapy community earlier in January, and for good reason: The new requirements state that CMS won't reimburse for certain activity and evaluation codes if they're used in the same day. APTA argues that accepted physical therapist practice often includes the startup of care on the same day as evaluation (and continued care on the same day as reevaluation), and that the prohibition runs counter to CMS' own aims for care.
Reaction: Since the announcement, Capitol Bridge, LLC, CMS' National Correct Coding Initiative (NCCI) contractor, has been inundated with comments from PTs, PTAs, and other stakeholders slamming the decision and requesting that the change be reversed. APTA is communicating with representatives from Capitol Bridge, CMS, and the American Medical Association, which plays a significant role in coding development.
Where things stand: As of the date of this report, no changes have been made. That leaves PTs and PTAs to deal with the current prohibition, as problematic as it may be.
To help you navigate the system as it is, here are answers to some of the most common questions we've been receiving on the NCCI coding change.
1. What are NCCI Procedure-to-Procedure (PTP) code pair edits?
NCCI PTP edits are intended to prevent payment of services that should not be reported together. Each edit has a Column One and Column Two Health Care Common Procedure/Current Procedural Terminology (HCPCS/CPT) code, called a “pair.” If a provider reports the two codes of a pair for the same beneficiary on the same date of service, only the Column One code is eligible for payment; the Column Two code is denied unless a clinically appropriate NCCI-associated modifier is also reported.
As for modifiers, each PTP edit has a modifier indicator, represented by (0), (1), and (9), that appears after the code number. Here's what those numbers mean:
- 0 - There are no circumstances in which a modifier would be appropriate. The services represented by the code combination will not be paid separately.
- 1 - A modifier is allowed in order to differentiate between the services provided. Assuming the modifier is used correctly and appropriately, this distinction provides the basis upon which separate payment for the services billed may be considered justifiable.
- 9 – The deletion date of the code pair is the same as the effective date. In other words, these edits are no longer active, so the code combinations are billable, and no other modifier is needed.
2. What happens if I bill 97530 (therapeutic activities) and 97161, 97162, or 97163 (physical therapy evaluations) together on same day for same patient?
This is at the heart of the recent edit. Under the new rules, the use of both codes is prohibited, and there's no modifier that you can use to bypass the denial. That includes the 59 modifier/X modifier: You can't use the 59 modifier/X modifier when billing 97530 with 97161, 97162, or 97163 to bypass the edit.
Bottom line: when 97530 and one of the physical therapy evaluation codes are billed together on the same day for the same patient, the evaluation code will be denied. This is because in the PTP edits list, 97530 is the Column One code and 97161, 97162, and 97163 are Column Two codes (see the answer to question 1 for more background on Column One and Column Two codes).
3. Why is 97530 (therapeutic activities) in Column One and 97161-97163 (physical therapy evaluations) in Column 2?
Good question. We believe this PTP edit is inconsistent with the general guidelines for PTP edits, and it's one of the reasons APTA and other stakeholders are working with CMS to have this edit removed as soon as possible.
4. What happens if I bill 97150 (group therapy) and 97161, 97162, or 97163 (physical therapy evaluations) together on the same day for same patient?
As with the therapeutic activities code covered in question 2, the answer is, you won't get reimbursed for the evaluation — and there is no modifier you can use to bypass the edit, including the 59 modifier/X modifier. This is because in the PTP edits list, 97150 is the Column One code and 97161, 97162, and 97163 are Column Two codes. Under the policy, when Column One and Column Two codes are billed, the Column One code is eligible for payment and the Column Two code is denied.
5. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97140 (manual therapy) and 97161-97163 (physical therapy evaluation codes)?
Yes. It's possible to bypass the edit by using the 59 modifier/X modifier when billing 97140 with the physical therapy evaluation codes (97161, 97162, or 97163). If you don't use the modifier for this combination of codes, CMS will deny the manual therapy code. This is because in the PTP edits list, 97161-97163 is the Column One code and 97140 is the Column Two code. Under the policy, when Column One and Column Two codes are billed, the Column One code is eligible for payment and the Column Two code is denied — unless an appropriate modifier is used.
6. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97530 (therapeutic activities) and 97164 (physical therapy re-evaluation)?
Yes, you are permitted to bill 97530 with 97164 if you use the 59 modifier/X modifier. If you do not bill with the appropriate modifier, then 97164 (Column Two code) will be denied. (See question 5).
7. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97150 (group therapy) and 97164 (physical therapy re-evaluation)?
Yes, for the same reason explained in questions 5 and 6.
8. Do PTP edits apply across disciplines?
Unfortunately yes, when services are billed under the same provider number. For example, if the occupational therapist performs 97530 on the same day as the PT who bills an evaluation code, the evaluation code will be denied if the services of both providers are billed under the same provider number (as in institutional billing).
9. What settings do PTP code pair edits apply to?
The NCCI edits consist of two provider-type choices of PTP code pair edits: practitioners and hospitals.
By "practitioners," CMS means that the NCCI edits apply to claims submitted by physicians, nonphysician practitioners, and ambulatory surgical centers. This includes PT private practitioners.
The definition of "hospital," for purposes of this edit, extends to outpatient hospital services and other facility services including, but not limited to, therapy providers in Part B skilled nursing facilities, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech-language pathology providers, and home health agencies for certain claims billed under Type of Bill (TOB) 22X, 23X, 75X, 74X, 34X.
10. Do NCCI edits apply to all third-party payers?
Yes and no. Technically, the NCCI edits only apply to Medicare fee-for-service, but the majority of commercial payers do use the NCCI edits in their systems, so there's a good chance you'll need to comply with the edits even if you aren't working with Medicare. Some workers compensation programs and self-insured plans may create their own edits.
11. Are there other edits I should be aware of?
Yes, there are many PTP edits for hospital and practitioner settings. The PTP edits are updated on a quarterly basis. To stay up to date, visit the CMS PTP Coding Edits page, scroll down to related links, and click on the appropriate setting link (Hospital PTP edit or Practitioner PTP edit) for the relevant time period.
12. What happens next?
APTA continues to pressure CMS to remove these edits. CMS has met with the NCCI contractor to discuss the edits and is working on a resolution. We hope to have additional information to share in the near future.
Looking for additional information about NCCI edits? Visit the National Correct Coding Initiative Edits webpage or contact APTA at advocacy@apta.org.