Effective Date: 7/3/2017
CR9933 implements the following payment policies related to professional claims for therapy services for the new CPT codes for PT and OT evaluative procedures – claims without the required information will be returned/rejected:
Therapy Modifiers
The new PT and OT codes are added to the current list of evaluative procedures that require a specific therapy modifier to identify the plan of care under which the services are delivered to be on the claim for therapy services. Therapy modifiers GP, GO, or GN are required to report the type of therapy plan of care – PT, OT, or speech-language pathology, respectively. This payment policy requires that each new PT evaluative procedure code – 97161, 97162, 97163 or 97164 – to be accompanied by the GP modifier; and, (b) each new code for an OT evaluative procedure – 97165, 97166, 97167 or 97168 – be reported with the GO modifier.
Functional Reporting
In addition to other Functional Reporting requirements, Medicare payment policy requires Functional Reporting, using G-codes and severity modifiers, when an evaluative procedure is furnished and billed. This notification adds the eight new codes for PT and OT evaluations and re-evaluations – 97161, 97162, 97163, 97164, 97165, 97166, 97167, and 97168 – to the procedure code list of evaluative procedures that necessitate Functional Reporting. A severity modifier (CH – CN) is required to accompany each functional G-code (G8978-G8999, G9158-9176, and G9186) on the same line of service.
For each evaluative procedure code, Functional Reporting requires either two or three functional G-codes and related severity modifiers be on the same claim. Two G-codes are typically reported on specified claims throughout the therapy episode. However, when an evaluative service is furnished that represents a one-time therapy visit, the therapy clinician reports all three G-codes in the functional limitation set – G-codes for Current Status, Goal Status and Discharge Status.
CMS coding requirements for Functional Reporting applied through CR9933 ensure that at least two G-codes in a functional set and their corresponding severity modifiers are present on the same claim with any one of the codes on this evaluative procedure code list. The required reporting of G-codes includes: (a) G-codes for Current Status and Goal Status; or, (b) G-codes for Discharge Status and Goal Status.
For the documentation requirements related to Functional Reporting, please refer to the “Medicare Benefits Policy Manual,” Chapter 15, Section 220.4, which is available at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf.
Claims Coding Requirements
Therapy Modifiers. Your MAC will return/reject professional claims when:
- Reporting codes 97161, 97162, 97163, or 97164 without the GP modifier.
- Reporting codes 97165, 97166, 97167, or 97168 without the GO modifier.
- Reporting an “always therapy” code without a therapy modifier
For these returned/rejected claims, your MAC will supply the following messages:
- Group code CO
- CARC – 4: The procedure code is inconsistent with the modifier used or a required modifier is missing.
Functional Reporting. Your MAC will return/reject claims when:
- The professional claims you submit for the new therapy evaluative procedures, codes 97161- 97168, without including one of the following pairs of G-codes/severity modifiers required for Functional Reporting: (a) A Current Status G-code/severity modifier paired with a Goal Status G-code/severity modifier; or, (b) A Goal Status G-code/severity modifier paired with a Discharge Status G-code/severity modifier.
Your MAC will provide the following remittance messages when returning such submissions:
- Group code of CO (contractual obligation)
- Claim Adjustment Reason Code (CARC) – 16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
- Remittance Advice Remarks Code (RARC) – N572: This procedure is not payable unless non-payable reporting codes and appropriate modifiers are submitted.
Reference
MLN Matters Number: MM9933
