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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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  • 17 Mar 2020 1:41 PM | Zachary Edgar (Administrator)

    Medicare is now allowing physical, occupational, and speech therapists to bill for E-visits with patients.

    E-VISITS:  In all types of locations including the patient’s home, and in all areas (not just rural), established Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals. These services can only be reported when the billing practice has an established relationship with the patient. For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would apply to these services.

    Medicare Part B also pays for E-visits or patient-initiated online evaluation and management conducted via a patient portal. Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes:

    • 99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes
    • 99422: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes
    • 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.

    Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can also provide these e-visits and bill the following codes:

    • G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes
    •  G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes
    • G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.

    KEY TAKEAWAYS:

    • These services can only be reported when the billing practice has an established relationship with the patient. 
    • This is not limited to only rural settings. There are no geographic or location restrictions for these visits.
    • Patients communicate with their doctors without going to the doctor’s office by using online patient portals.
    • Individual services need to be initiated by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient initiation. 
    • The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable.
    • The Medicare coinsurance and deductible would generally apply to these services.

    HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA):  Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.  For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html


    Reference

    Medicare Telemedicine Health Care Provider Fact SheetMar 17, 2020, available at https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet


  • 13 Mar 2020 11:07 AM | Zachary Edgar (Administrator)

    Upcoming Webinar: Telehealth for Physical and Occupational Therapy

    March 25, 2020 at 12:00 PM - 1:00 PM CDT

    April 1, 2020 at 12:00 PM - 1:00 PM EDT

    Telehealth and Other Communication-Based Technology Services

    Beneficiaries can communicate with their doctors or certain other practitioners without necessarily going to the doctor’s office in person for a full visit.

    Since 2018, Medicare pays for “virtual check-ins” for patients to connect with their doctors without going to the doctor’s office. These brief, virtual check-in services are for patients with an established relationship with a physician or certain practitioners where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to using virtual check-ins and the consent must be documented in the medical record prior to the patient using the service. The Medicare coinsurance and deductible would apply to these services.

    Doctors and certain practitioners may bill for these virtual check-in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012) or captured video or image (HCPCS code G2010).

    Medicare also pays for patients to communicate with their doctors without going to the doctor’s office using online patient portals. The individual communications, like the virtual check ins, must be initiated by the patient; however, practitioners may educate beneficiaries on the availability of this kind of service prior to patient initiation. The communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable. The Medicare coinsurance and deductible would apply to these services.

    In addition, Medicare beneficiaries living in rural areas may use communication technology to have full visits with their physicians. The law requires that these visits take place at specified sites of service, known as telehealth originating sites, and receive services using a real-time audio and video communication system at the site to communicate with a remotely located doctor or certain other types of practitioners. Medicare pays for many medical visits through this telehealth benefit. Certain beneficiaries, such as those needing a monthly end-stage renal disease visit or those needing treatment for substance use disorders or co-occurring mental health disorder may access telehealth services from their home without traveling to an originating site.

    The Medicare coinsurance and deductible would apply to these services.

    Medicare also pays doctors for certain non-face-to-face care management services and remote patient monitoring services. The Medicare coinsurance and deductible would apply to these services.

    References

    CMS Fact Sheet Coverage and Payment Related to COVID-19 Medicare Posted March 3, 2020


  • 13 Mar 2020 10:56 AM | Zachary Edgar (Administrator)

    On March 10, 2020 CMS published guidance on Home Health Agencies and the COVID-19 (Coronavirus).  The full document can be accessed here: https://www.cms.gov/files/document/qso-20-18-hha.pdf

    Background

    The Centers for Medicare & Medicaid Services (CMS) is committed to the protection of patients in the home care setting from the spread of infectious disease. This memorandum responds to questions we have received and provides important guidance for all Medicare and Medicaid participating Home Health Agencies (HHAs) in addressing the COVID-19 outbreak and minimizing transmission to other individuals.

    Guidance

    HHAs should monitor the CDC website (see links below) for information and resources and contact their local health department when needed. Also, HHAs should be monitoring the health status of everyone (patients/residents/visitors/staff/etc.) in the homecare setting for signs or symptoms of COVID-19. Per CDC, prompt detection, triage and isolation of potentially infectious patients are essential to prevent unnecessary exposures among patients, healthcare personnel, and visitors.

    HHA Guidance for Admitting and Treating Patients with known or suspected COVID-19 

    Which patients are at risk for severe disease for COVID-19?

    Based upon CDC data, older adults or those with underlying chronic medical conditions may be most at risk for severe outcomes.

    How should HHAs screen patients for COVID-19?

    When making a home visit, HHAs should identify patients at risk for having COVID-19 infection before or immediately upon arrival to the home. They should ask patients about the following:

    1. International travel within the last 14 days to countries with sustained community transmission. For updated information on affected countries visit: https://www.cdc.gov/coronavirus/2019-ncov/travelers/index.html

    2. Signs or symptoms of a respiratory infection, such as a fever, cough, and sore throat.

    3. In the last 14 days, has had contact with someone with or under investigation for COVID19, or are ill with respiratory illness. 4. Residing in a community where community-based spread of COVID-19 is occurring.

    For ill patients, implement source control measures (i.e., placing a facemask over the patient’s nose and mouth if that has not already been done).

    Inform the HHA clinical manager, local and state public health authorities about the presence of a person under investigation (PUI) for COVID-19. Additional guidance for evaluating patients in U.S. for COVID-19 infection can be found on the CDC COVID-19 website.

    CMS regulations requires that home health agencies provide the types of services, supplies and equipment required by the individualized plan of care. HHA’s are normally expected to provide supplies for respiratory hygiene and cough etiquette, including 60%-95% alcohol-based hand sanitizer (ABHS). State and Federal surveyors should not cite home health agencies for not providing certain supplies (e.g., personal protective equipment (PPE) such as gowns, respirators, surgical masks and alcohol-based hand rubs (ABHR)) if they are having difficulty obtaining these supplies for reasons outside of their control. However, we do expect providers/suppliers to take actions to mitigate any resource shortages and show they are taking all appropriate steps to obtain the necessary supplies as soon as possible.

    How should HHAs monitor or restrict home visits for health care staff?

    • Health care providers (HCP) who have signs and symptoms of a respiratory infection should not report to work.
    • Any staff that develop signs and symptoms of a respiratory infection while on-the-job, should:

    o Immediately stop work, put on a facemask, and self-isolate at home;

    o Inform the HHA clinical manager of information on individuals, equipment, and locations the person came in contact with; and

    o Contact and follow the local health department recommendations for next steps (e.g., testing, locations for treatment).

    • Refer to the CDC guidance for exposures that might warrant restricting asymptomatic healthcare personnel from reporting to work (https://www.cdc.gov/coronavirus/2019- ncov/hcp/guidance-risk-assesment-hcp.html)

    Do all patients with known or suspected COVID-19 infection require hospitalization?

    Patients may not require hospitalization and can be managed at home if they are able to comply with monitoring requests. More information is available here: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html

    What are the considerations for determining when patients confirmed with COVID-19 are safe to be treated at home?

    Although COVID-19 patients with mild symptoms may be managed at home, the decision to remain in the home should consider the patient’s ability to adhere to isolation recommendations, as well as the potential risk of secondary transmission to household members with immunocompromising conditions. More information is available here: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-home-care.html

    When should patients confirmed with COVID-19 who are receiving HHA services be considered for transfer to a hospital?

    Initially, symptoms maybe mild and not require transfer to a hospital as long as the individual with support of the HHA can follow the infection prevention and control practices recommended by CDC. 

    The patient may develop more severe symptoms and require transfer to a hospital for a higher level of care. Prior to transfer, emergency medical services and the receiving hospital should be alerted to the patient’s diagnosis, and precautions to be taken including placing a facemask on the patient during transfer. If the patient does not require hospitalization they can be discharged back to home (in consultation with state or local public health authorities) if deemed medically and environmentally appropriate. Pending transfer or discharge, place a facemask on the patient and isolate him/her in a room with the door closed.

    What are the implications of the Medicare HHA Discharge Planning Regulations for Patients with COVID-19?

    Medicare’s Discharge Planning Regulations (which were updated in November 2019) requires that HHA assess the patient’s needs for post-HHA services, and the availability of such services. When a patient is discharged, all necessary medical information (including communicable diseases) must be provided to any other service provider. For COVID-19 patients, this must be communicated to the receiving service provider prior to the discharge/transfer and to the healthcare transport personnel.

    What are recommended infection prevention and control practices, including considerations for family member exposure, when evaluating and caring for patients with known or suspected COVID-19?

    The CDC advises the patient to stay home except to get medical care, separate yourself from other people and animals in the home as much as possible (in a separate room with the door closed), call ahead before visiting your doctor, and wear a facemask in the presence of others when out of the patient room. For everyone in the home, CDC advises covering coughs and sneezes followed by hand washing or using an alcohol-based hand rub, not sharing personal items (dishes, eating utensils, bedding) with individuals with known or suspected COVID-19, cleaning all “high-touch” surfaces daily, and monitoring for symptoms. We would ask that HHA’s share additional information with families.

    Are there specific considerations for patients requiring therapeutic interventions?

    Patients with known or suspected COVID-19 should continue to receive the intervention appropriate for the severity of their illness and overall clinical condition. Because some procedures create high risks for transmission (close patient contact during care) precautions include: 1) HCP should wear all recommended PPE, 2) the number of HCP present should be limited to essential personnel, and 3) any supplies brought into, used, and removed from the home must be cleaned and disinfected in accordance with environmental infection control guidelines. 

    What Personal Protective Equipment should home care staff routinely use when visiting the home of a patient suspected of COVID-19 exposure or confirmed exposure?

    If care to patients with respiratory or gastrointestinal symptoms who are confirmed or presumed to be COVID-19 positive is anticipated, then HHAs should refer to the Interim Guidance for Public Health Personnel Evaluating Persons Under Investigation (PUIs) and Asymptomatic Close Contacts of Confirmed Cases at Their Home or Non-Home Residential Settings: https://www.cdc.gov/coronavirus/2019-ncov/php/guidance-evaluating-pui.html

    Hand hygiene should be performed before putting on and after removing PPE using alcoholbased hand sanitizer that contains 60 to 95% alcohol.

    PPE should ideally be put on outside of the home prior to entry into the home. If unable to put on all PPE outside of the home, it is still preferred that face protection (i.e., respirator and eye protection) be put on before entering the home. Alert persons within the home that the public health personnel will be entering the home and ask them to move to a different room, if possible, or keep a 6-foot distance in the same room. Once the entry area is clear, enter the home and put on a gown and gloves.

    Ask person being tested if an external trash can is present at the home, or if one can be left outside for the disposal of PPE. PPE should ideally be removed outside of the home and discarded by placing in external trash can before departing location. PPE should not be taken from the home of the person being tested in public health personnel’s vehicle.

    If unable to remove all PPE outside of the home, it is still preferred that face protection (i.e., respirator and eye protection) be removed after exiting the home. If gown and gloves must be removed in the home, ask persons within the home to move to a different room, if possible, or keep a 6-foot distance in the same room. Once the entry area is clear, remove gown and gloves and exit the home. Once outside the home, perform hand hygiene with alcohol-based hand sanitizer that contains 60 to 95% alcohol, remove face protection and discard PPE by placing in external trash can before departing location. Perform hand hygiene again.

    When is it safe to discontinue Transmission-based Precautions for home care patients with COVID-19?

    The decision to discontinue Transmission-Based Precautions for home care patients with COVID-19 should be made in consultation with clinicians, infection prevention and control specialists, and public health officials. This decision should consider disease severity, illness signs and symptoms, and results of laboratory testing for COVID-19 in respiratory specimens. For more details, please refer to: https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-inhome-patients.html.

    Considerations to discontinue in-home isolation include all of the following:

    o Resolution of fever, without use of antipyretic medication

    o Improvement in illness signs and symptoms

    o Negative results of an FDA Emergency Use Authorized molecular assay for COVID-19 from at least two consecutive sets of paired nasopharyngeal and throat swabs specimens collected ≥24 hours apart* (total of four negative specimens— two nasopharyngeal and two throat). See Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Patients Under Investigation (PUIs) for 2019 Novel Coronavirus (2019-nCoV) for specimen collection guidance.

    Protocols for Coordination and Investigation of Home Health Agencies with Actual or Suspected COVID-19 Cases

    During a home health agency survey, when a COVID-19 confirmed case or suspected case (including PUI) is identified, the surveyors will confirm that the agency has reported the case to public health officials as required by state law and will work with the agency to review infection prevention and education practices. Confirm that the HHA has the most recent information provided by the CDC.

    • The State should notify the appropriate CMS Regional Office of the HHA who has been identified as providing services to a person with confirmed or suspected COVID19 (including persons under investigation) who do not need to be hospitalized;

    • The State should notify the appropriate CMS Regional Office of the HHA who has been identified as providing services to a person with confirmed COVID-19 who were hospitalized and determined to be medically stable to go home.

  • 4 Mar 2020 12:14 PM | Zachary Edgar (Administrator)

    Texas Physical Therapy Telehealth Rule Changes

    Effective March 1, 2020

    §322.5. Telehealth

    (a) When used in the rules of the Texas Board of Physical Therapy Examiners, telehealth is the use of telecommunications or information technology to provide physical therapy services to a patient who is physically located at a site in Texas other than the site where the physical therapist or physical therapist assistant is located, whether or not in Texas.

    (b) Physical therapy telehealth services must be provided by a physical therapist or physical therapist assistant under the supervision of the physical therapist who possesses a current:

    (1) unrestricted Texas license; or

    (2) Compact Privilege to practice in Texas.

    (c)The provision of physical therapy services via telehealth requires synchronous audiovisual or audio interaction between the physical therapist or physical therapist assistant and the patient/client, which may be accompanied by the use of asynchronous store and forward technology.

    (d) Standard of Care. A physical therapist or physical therapist assistant that provides telehealth services:

    (1) is subject to the same standard of care that would apply to the provision of the same physical therapy service in an in-person setting; and

    (2) the physical therapist is responsible for determining whether an evaluation or intervention may be conducted via telehealth or must be conducted in an in-person setting.

    (e) Informed Consent. A physical therapist that provides telehealth services must obtain and maintain the informed consent of the patient, or of another individual authorized to make health care treatment decisions for the patient, prior to the provision of telehealth services.

    (f) Confidentiality. A physical therapist or physical therapist assistant that provides telehealth services must ensure that the privacy and confidentiality of the patient's medical information is maintained during and following the provision of telehealth services, including compliance with HIPAA regulations and other federal and state law.

    (g) The failure of a physical therapist or physical therapist assistant to comply with this section shall constitute detrimental practice and could subject the licensee to disciplinary action by the Board.

    (h) Provision of telehealth services by a physical therapist assistant must occur under the supervision of the physical therapist in accordance with rule §322.3 of this title. [(h) A physical therapist assistant may not provide telehealth services but may be present at the same location as the patient to assist the physical therapist in providing telehealth services.]

    (i) Telehealth is a mode for providing one-on-one physical therapy services to a patient/client and is not a means for supervision of [physical therapist assistants or] physical therapy aides.

    Reference

    3 Texas Admin. Code § 322.5

  • 17 Feb 2020 4:13 PM | Zachary Edgar (Administrator)

    More information on NCCI

    As of 2/4/2020

    CMS made the decision to delete the January 1, 2020 PTP edits for Current Procedural Terminology (CPT) code pairs:

    The edits prevented billing therapeutic activities or group therapy with a PT/OT/AT evaluation.

    97530/97150 – 97161;

    97530/97150 – 97162;

    97530/97150 – 97163;

    97530/97150 – 97165;

    97530/97150 – 97166;

    97530/97150 – 97167;

    97530/97150 – 97169;

    97530/97150 – 97170;

    97530/97150 – 97171; and

    97530/97150 – 97172.


  • 27 Jan 2020 10:11 AM | Zachary Edgar (Administrator)

    As of January 1, 2020, Humana now requires claims for therapy services provided in whole or in part by PTAs and OTAs to be submitted with the CO or CQ modifiers.  Follow the guidance provided by CMS.

    Modifier CO: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.

    Modifier CQ: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant.

    The policy applies to all Humana Medicare Advantage and commercial payment policies.  And applies to every charge for an occupational or physical therapy service paid on an outpatient basis reported on either a professional or an institutional claim except for an institutional type of bill 85x claim.

    Effective for dates of service beginning January 1, 2022, Humana allows a charge for an outpatient OTA or PTA service at 85% of the contracted rate or base maximum amount payable under the member’s plan, if, as discussed in the requirement above, modifier CO or CQ would have been appropriate for that service.

    Reference

    Humana Claims Payment Policy

    CP2018009


  • 31 Dec 2019 1:20 PM | Zachary Edgar (Administrator)

    Two New Biofeedback Codes to Replace CPT Code 90911

    The two new “sometimes therapy” codes with their CPT long descriptors, are as follows:

    CPT code 90912 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including electromyography (EMG) and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient.

    CPT code 90913 - Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure).

    Codes to Replace 97127

    The CPT Editorial Panel also created, for CY 2020; CPT codes 97129 and 97130 to replace CPT code 97127, which CMS did not recognize.

    These new codes will effectively replace HCPCS code G0515, which will be deleted, effective January 1, 2020.

    These codes are designated “sometimes therapy” to permit physicians, NPPs, and psychologists to furnish these services outside a therapy plan of care when appropriate.

    CPT code 97129 - Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; initial 15 minutes

    CPT code 97130 - Therapeutic interventions that focus on cognitive function (eg, attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact; each additional 15 minutes (List separately in addition to code for primary procedure)

    Deleted Codes

    The CPT Editorial Panel also deleted the following codes for manual muscle testing for CY 2020: CPT codes 95831, 95832, 95833, and 95834.

    The following 42 HCPCS Level II G-codes are deleted for dates of service after December 31, 2019:

    • HCPCS codes G8978 through G8999; G9158 through G9176; and G9186

    References

    MLN Matters Number: MM11501


  • 6 Nov 2019 1:00 PM | Zachary Edgar (Administrator)

    KX Modifier: The threshold amount for when therapists are required to use the modifier will be $2,080 for physical therapy and speech-language pathology services combined, and $2,080 for occupational therapy alone.

    Targeted Medical Review: The threshold will remain the same at $3000.

    Biofeedback Codes: “Sometimes therapy”.  Codes related to biofeedback training of perineal muscles or anorectal or urethral sphincters have been added to the biofeedback family, and valued at .90 work RVU for the initial 15 minutes of treatment and .50 work RVU for each additional 15 minutes of one-on-one contact.

    Negative Wound Pressure: CMS has established relative value units (RVU) and direct practice expense inputs for codes associated with negative wound pressure therapy, with a .41 work RVU for code 97607 (vacuum-assisted drainage collection for total wound surface area of 50 square centimeters or fewer) and .46 work RVU for 97608 (vacuum-assisted drainage collection for total wound surface area of 51 square centimeters or more).

    Important Changes to the CO/CQ Modifiers

    Summary:

    • When the PT/OT is involved for the entire duration of the service and the PTA/OTA provides skilled therapy alongside the therapist, the CQ/CO modifier isn't required.
    • When the same service is furnished separately by the PT/OT and the PTA/OTA, the 10 percent standard will apply to each 15-minute unit, not the total time that was spent on the service.
    • CMS will not require additional information about time and the application of the modifiers to treatment notes.

    PT/OT and PTA/OTA Providing a Therapeutic Service at the Same time

    Proposed: In the proposed rule CMS planned to require that the time for the therapeutic service furnished “in part” by the PTA/OTA that counts towards the 10 percent standard includes both the minutes spent concurrently with and separately from the therapist.  For, example is the PT/OT was doing an evaluation and the PTA/OTA assisted during that evaluation then the 10% de minimus standard would apply, most likely requiring the CO/CQ modifier.

    Final rule: Only the minutes that the PTA/OTA spends independent of the therapist will count towards the 10 percent de minimis standard.

    “We agree with commenters that we should not count the time when a therapist and a therapist assistant furnish services to the same patient at the same time. We believe this interpretation is appropriate because we agree with commenters that when a therapist and therapist assistant furnish services together, the therapist is fully furnishing the service. Also, any time that the therapy assistant furnishes services alone or independent of the therapist is time that the therapist can be credited for furnishing services to a different patient.”

    Apply the Modifiers to 15-Minute Units

    Proposed: CMS proposed to apply the 10 percent time standard, for billing purposes, to all the billed units of a service defined by a single procedure code.  For example, the PT/OT and PTA/OTA each separately, exclusive of the other, furnish minutes of the same therapeutic exercise service (HCPCS code 97110) in different time frames: The PT/OT furnishes twenty (20) minutes and the PTA/OTA furnishes twenty-five (25) minutes for a total of forty-five (45) minutes, three (3) units can be billed using the total time minute range of at least thirty-eight (38) minutes and up to fifty-two (52) minutes.

    All three (3) units of CPT code 97110 are reported on the claim with the corresponding CQ/CO modifier because the twenty-five (25) minutes furnished by the PTA/OTA exceeds ten (10%) percent of the forty-five (45) minute total service time (4.5 minutes rounded to five (5) minutes, so the modifier would apply if the PTA/OTA had furnished six (6) or more minutes of the service).

    Final Rule: CMS will allow the separate reporting, on two different claim lines, of the number of 15-minute units of a code to which the therapy assistant modifiers do not apply, and the number of 15-minute units of a code to which the therapy assistant modifiers do apply.  The 10 percent standard will be applied to each billed unit of a timed code rather than to all billed units of a timed code, and the billing on two separate claim lines of the units of a timed code to which the therapy assistant modifiers do and do not apply.

    Treatment Notes

    Proposed Rule: CMS proposed to require additional information to the treatment notes.  For example, CPT 97110- Assistant provided 8 minutes, Therapist provided 24 minutes” and “CPT 97530- Assistant provided 22 minutes, Therapist provided 0 minutes.”

    Final Rule: CMS will not require the additional information to each note.  The documentation guidelines already require the identification of the individual/s that provided the treatment and a record of the time spent. 


  • 22 Oct 2019 12:41 PM | Zachary Edgar (Administrator)

    Live Webinar:

    October 30, 2019 at 12:00 PM CDT

    October 31, 2019 at 12:00 PM EDT

    In 2022, Medicare will apply a 15% discount to payments for therapy that is provided, “in whole” or “in part”, by a PTA or OTA. 

    To prepare for this change, claims for outpatient therapy services furnished “in whole or in part” by a therapy assistant must include the new modifier effective for dates of service beginning on January 1, 2020.

    The New Modifiers

    CQ Modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant.

    CO Modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.

    Settings

    The CO and CQ modifiers with need to be used for all outpatient therapy services provided by:

    • Therapists in private practice;
    • Physicians’ offices;
    • Rehabilitation agencies;
    • Public health agencies
    • Comprehensive outpatient rehabilitation facilities (CORFs);
    • Home health agencies;
    • Skilled nursing facilities; and
    • A hospital to an outpatient or to a hospital inpatient who is entitled to benefits under part A but has exhausted benefits for inpatient hospital services during a spell of illness or is not so entitled to benefits under part A.

    Outpatient therapy services provided by critical access hospitals (CAH) are exempt from the requirement.

    Services

    The CQ/CO modifier applies to all services that would be billed with the respective GP or GO therapy modifier, i.e. under either a physical or occupational plan of care.

    When the Modifiers are Applied

    The modifiers are applicable to:

    • Therapeutic portions of outpatient therapy services furnished by PTAs/ OTAs, as opposed to administrative or other non-therapeutic services that can be performed by others without the education and training of OTAs and PTAs.
    • Services wholly furnished by PTAs or OTAs without physical or occupational therapists.
    • Evaluative services that are furnished in part by PTAs/OTAs (keeping in mind that PTAs/OTAs are not recognized to wholly furnish PT and OT evaluation or re-evaluations).

    They do not apply when:

    • PTAs/OTAs furnish services that can be done by a technician or aide who does not have the training and education of a PTA/OTA.  (Services not Covered)
    • Therapists exclusively furnish services without the involvement of PTAs/OTAs.

    The De Minimis Standard

    To determine whether the services were “furnished in whole or in part by a PTA or OTA”, CMS has come up with a de minimis standard.  When more than ten (10%) percent of the service is furnished by the PTA or OTA the modifiers will need to be attached.

    The ten (10%) percent calculation will be based on the respective therapeutic minutes of time spent by the therapist and the PTA/OTA, rounded to the nearest whole minute.

    The total time for a service would be the total time spent by the therapist (whether independent of, or concurrent with, a PTA/OTA) plus any additional time spent by the PTA/OTA independently furnishing the therapeutic service.

    Concurrent Services

    If the PTA/OTA participates in the service concurrently with the therapist for only a portion of the total time that the therapist delivers a service, the CQ/CO modifiers apply when the minutes furnished by the therapy assistant are greater than ten (10%) percent of the total minutes spent by the therapist furnishing the service.

    Concurrent minutes: When PTA/OTA’s minutes are furnished concurrently with the therapist, total time equals the total minutes of the therapist’s service.

    Separate Portions of the Same Service

    If the PTA/OTA and the therapist each separately furnish portions of the same service, we propose that the CQ/CO modifiers would apply when the minutes furnished by the therapy assistant are greater than 10 percent of the total minutes—the sum of the minutes spent by the therapist and therapy assistant—for that service.

    Separate minutes: When PTA/OTA’s minutes are furnished separately from the minutes furnished by the therapist, total time equals the sum of the minutes of the service furnished by the PT/OT plus the minutes of the service furnished separately by the PTA/OTA.

    Two Methods to Calculate the Ten (10%) Percent Standard

    Method One

    Total Time

    • The therapist’s total time when PTA/OTA minutes are furnished concurrently with the therapist, or
    • The sum of the PTA/ OTA and therapist minutes when the PTA/OTA’s services are furnished separately from the therapist.

    Step one: Divide the PTA/OTA minutes by the total minutes for the service.

    Step two: Multiply this number by 100 to calculate the percentage of the service that involves the PTA/OTA.

    Step three: Round to the nearest whole number so that when this percentage is eleven (11%) percent or greater, the ten (10%) percent de minimis standard is exceeded and the CQ/CO modifier is applied.

    Method Two

    Total Time

    • The therapist’s total time when PTA/OTA minutes are furnished concurrently with the therapist, or
    • The sum of the PTA/ OTA and therapist minutes when the PTA/OTA’s services are furnished separately from the therapist;

    Step one: Divide the total time for the service by ten (10) to identify the ten (10%) percent de minimis standard.

    Step two (if applicable): Round the minutes and percentages of the service to the nearest whole integer. For example, when the total time for the service is forty-five (45) minutes, the ten (10%) percent calculation would be 4.5 which would be rounded up to five (5).

    Step three: Add one (1) minute to identify the number of minutes of service by the PTA/OTA that would be needed to exceed the ten (10%) percent standard.

    Example: Total time of a service is sixty (60) minutes, the ten (10%) percent standard is six (6) minutes and adding one (1) minute yields seven (7) minutes. Once the PTA/OTA furnishes at least seven (7) minutes of the service, the CQ/ CO modifier is required to be added to the claim for that service.

    Method Two: Method to apply 10 percent de minimis standard

    Total Time * examples using typical service total times

    Determine the 10 percent standard by dividing service Total Time by 10

    Round 10 percent standard to next whole integer

    PTA/OTA Minutes needed to exceed—apply CQ/CO

    10

    15

    20

    30

    45

    60

    75

    1.0

    1.5

    2.0

    3.0

    4.5

    6.0

    7.5

    1.0

    2.0

    2.0

    3.0

    5.0

    6.0

    8.0

    2.0

    3.0

    3.0

    4.0

    6.0

    7.0

    9.0


    Times and Untimed Codes

    Evaluations and Re-evaluations

    These PT and OT evaluative procedures are untimed codes and cannot be billed in multiple units—one unit is billed on the claim.

    PTAs/OTAs are not recognized to furnish evaluative or assessment services, but to the extent that they furnish a portion of an evaluation or reevaluation (such as completing clinical labor tasks for each code) that exceeds the ten (10%) percent de minimis standard, the appropriate therapy assistant modifier (CQ or CO) must be used on the claim.

    Example: When the PTA/ OTA assists the PT/OT concurrently for a five (5) minute portion of the thirty (30) minutes that a PT or OT spent furnishing an evaluation, the respective CQ or CO modifier is applied to the service because the five (5) minutes surpasses the ten (10%) percent de minimis standard.

    Group Therapy

    CPT code 97150 (requires constant attendance of therapist or assistant, or both). CPT code 97150 describes a service furnished to a group of 2 or more patients. Like evaluative services, this code is an untimed service and cannot be billed in multiple units on the claim, so one unit of the service is billed for each patient in the group.

    For the group service, the CQ/CO modifier would apply when the PTA/OTA wholly furnishes the service without the therapist. The CQ/CO modifier would also apply when the total minutes of the service furnished by the PTA/OTA (whether concurrently with, or separately from, the therapist), exceed ten (10%) percent of the total time, in minutes, of the group therapy service (that is, the total minutes of service spent by the therapist (with or without the PTA/ OTA) plus any minutes spent by the PTA/OTA separately from the therapist).

    Example: The modifiers would apply when the PTA/OTA participates concurrently with the therapist for five (5) minutes of a total group therapy service time of forty (40) minutes (based on the time of the therapist); or when the PTA/OTA separately furnishes five (5) minutes of a total group time of forty (40) minutes (based on the sum of minutes of the PTA/OTA (5) and therapist (35)).

    Supervised Modalities

    CPT codes 97010 through 97028, and HCPCS codes G0281, G0183, and G0329. Modalities, in general, are physical agents that are applied to body tissue in order to produce a therapeutic change through various forms of energy, including but not limited to thermal, acoustic, light, mechanical or electric. Supervised modalities, for example vasopneumatic devices, paraffin bath, and electrical stimulation (unattended), do not require the constant attendance of the therapist or supervised therapy assistant, unlike the modalities defined in 15-minute increments.

    For supervised modalities, the CQ or CO modifier would apply to the service when the PTA/OTA fully furnishes all the minutes of the service, or when the minutes provided by the PTA or OTA exceed 10 percent of total minutes of the service.

    Example: The CQ/CO modifiers would apply when either:

    (1) the PTA/OTA concurrently furnishes two (2) minutes of a total eight (8) minute service by the therapist furnishing paraffin bath treatment (HCPCS code 97018) because two (2) minutes is greater than ten (10%) percent of eight (8) minutes (0.8 minute, or 1 minute after rounding); or

    (2) the PTA/OTA furnishes three (3) minutes of the service separately from the therapist who furnishes five (5) minutes of treatment for a total time of eight (8) minutes (total time equals the sum of the PT/OT minutes plus the separate PTA/OTA minutes) because three (3) minutes is greater than ten (10%) percent of eight (8) total minutes (0.8 minute rounded to 1 minute).

    Timed Codes

    Step One: The therapist or therapy assistant needs to first identify all timed services furnished to a patient on that day, and then total all the minutes of all those timed codes.

    Step Two: The therapist or therapy assistant needs to identify the total number of units of timed codes that can be reported on the claim for the physical or occupational therapy services for a patient in one treatment day.

    Step Three: Once the number of billable units is identified, the therapist or therapy assistant assigns the appropriate number of unit(s) to each timed service code according to the total time spent furnishing each service.

    Treatment Notes

    Proposed Requirement

    When PTAs/OTAs assist PTs/OTs to furnish services, the treatment note could state one of the following, as applicable:

    ‘‘Code 97110: CQ/CO modifier applied—PTA/ OTA wholly furnished’’; or,

    ‘‘Code 97150: CQ/CO modifier applied—PTA/ OTA minutes = 15%’’; or ‘‘Code 97530: CQ/CP modifier not applied—PTA/OTA minutes less than 10% standard.’’

    For those therapy services furnished exclusively by therapists without the use of PTAs/OTA, the PT/OT could note one of the following: ‘‘CQ/CO modifier NA’’, or ‘‘CQ/CO modifier NA—PT/OT fully furnished all services.’’

    Reference

    84 FR 40482



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