Upcoming Webinars

Site Updates

Disclaimer

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.

Menu
Log in
Forgot password


Search
Log in
Forgot password

Medicare Updates

  • 2022 Annual Update to the Therapy Code List

    10 Nov 2021 1:03 PM | Zachary Edgar (Administrator)

    Issue Date: 11/10/2021

    Effective Date: 1/3/2022

    CMS is adding 5 CPT codes and long descriptors as “sometimes therapy” codes effective for dates of service on or after January 1, 2022. The 5 CPT added codes are:

    • CPT code 98975 ─ Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment

    • CPT code 98976 ─ Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days

    • CPT code 98977 ─ Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days

    • CPT code 98980 ─ Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes

    • CPT code 98981 ─ Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure)

    We designated these CPT codes as “sometimes therapy” to allow physicians and certain Nonphysician Practitioners (NPPs), including nurse practitioners, physician assistants, and clinical nurse specialists to provide these services outside a therapy plan of care when appropriate. When therapists provide these "sometimes therapy" services, they’re “always therapy.” This means you must use the appropriate therapy modifier – GP, GO or GN -- to reflect that it’s under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively.

    We consider these 5 CPT codes to be remote therapeutic monitoring (RTM) services that physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists can provide, when appropriate. The RTM treatment management services described by CPT codes 98980 and 98981 are provided remotely to patients in their homes by therapists in private practice (TPPs) and facility-based therapists. For example, therapists who work in rehabilitation agencies and comprehensive outpatient rehabilitation facilities would provide these services. You would do the RTM service for the initial set-up and patient education on use of equipment (CPT code 98975) in the office or in the patient’s home.

    When physicians, NPPs, or therapists don’t directly perform the services, they must be done under direct supervision. While you must always provide therapists’ services under therapy plans of care, RTM services related to a RTM device that’s specific to therapy services, such as the ARIA Physical Therapy supply device in CPT code 98977 that includes therapeutic exercises, must also be provided under a therapy plan of care when provided by physicians and NPPs. If PTs and OTs delegate the RTM services to physical therapist assistants and occupational therapy assistants, respectively, they’re subject to the de minimis standard (with the exception of the 2 CPT codes for the RTM devices).

    Reference

    Centers for Medicare and Medicaid

    MLN Matters Number: MM12446


  • Low Utilization Payment Adjustment (LUPA) Add-on Amounts for Home Health (HH) Occupational Therapy Visits and Corrections to Payment Grouping Processes

    6 Aug 2021 1:04 PM | Zachary Edgar (Administrator)

    Issue Date: 8/6/2021

    Effective Date: 1/32/2022

    This change request makes changes to Original Medicare systems to allow for LUPA add-on payments to apply if an occupational therapy visit is the first visit in a period of care.

    Background

    Under the Consolidated Appropriations Act, 2021 (CAA 2021), the regulations at §§ 484.55(a)(2) and 484.55(b)(3) were revised to allow Occupational Therapists (OTs) to conduct initial and comprehensive assessments for all Medicare beneficiaries under the home health benefit when the plan of care does not initially include skilled nursing care. That is, occupational therapists may conduct the initial assessment and complete the comprehensive assessment, but only when occupational therapy is on the home health plan of care with either physical therapy and/or speech therapy and skilled nursing services are not initially on the plan of care. Because of this change, CMS must establish a LUPA add-on factor in calculating the LUPA add-on payment amount for the first skilled occupational therapy visit in LUPA periods that occur as the only period of care or the initial 30-day period of care in a sequence of adjacent 30- day periods of care.

    This change request also contains requirements to ensure consistent and accurate processing of HH claims under the Patient-Driven Groupings Model.

    All HH claims are matched to their associated Outcomes and Assessment Information System (OASIS) assessment during processing and use certain OASIS items to determine the Health Insurance Prospective Payment System (HIPPS) code used for payment. Medicare Administrative Contractors (MACs) have reported intermittent failures in the claims-OASIS matching process. When MACs observe unusually high volumes of HH claims in suspense locations awaiting a match, they may recycle the claims to the assessment system a second time. Per instructions in publication 100-04, chapter 10, section 10.1.10.1, MACs may take this action at their discretion or when notified by CMS. Requirements four and five ensure the recycled claims process correctly in all cases.

    Similarly, on all HH claims, the HH Grouper program must calculate the HIPPS code used for payment. MACs have reported intermittent cases where HH claims bypass the HH Grouper and have paid using the provider-submitted HIPPS code. Requirement six creates a safeguard to prevent this.

    Policy

    Currently, there are no sufficient data regarding the average excess of minutes for the first visit in LUPA periods where the initial and comprehensive assessments are conducted by OTs. Therefore, in the Calendar Year (CY) 2020 HH Prospective Payment System (PPS) final rule, CMS finalized to utilize the Physical Therapy (PT) LUPA add-on factor of 1.6700 as a proxy for the OT LUPA add-on factor for CY 2022 until we have CY 2022 data to establish the OT add-on factor for the LUPA add-on payment amounts in future years. The similarity in the per-visit payment rates for both PT and OT make the PT LUPA add-on factor the most appropriate proxy until CMS has sufficient data to establish the OT LUPA add-on factor.

    Reference

    Centers for Medicare & Medicaid Services

    Transmittal 10919


  • Changes to Medicare Enrollment of PTs, OTs, and SLPs

    22 Jun 2021 1:34 PM | Zachary Edgar (Administrator)

    Visit our Medicare Enrollment Page for updated criteria for physical, occupational, and speech therapists to enroll in Medicare as private practitioners. 

  • Reason Code Updates for the 2020 Annual Therapy Current Procedural Terminology (CPT) Codes in Change Request (CR) 11501

    31 Jul 2020 11:34 AM | Zachary Edgar (Administrator)

    Background: On January 6, 2020, CR11501 titled, 2020 Annual Update to the Therapy Code was implemented to prepare the Medicare systems to accept the updated CPT therapy code changes. CMS was made aware that there was an issue where claims were receiving reason codes for the updates to the 2020 therapy codes. This CR allows the Fiscal Intermediary Shared System (FISS) to update any necessary logic or reason codes needed for the CPT therapy codes, which were previously implemented in CR11501.

    Policy: The policies implemented in this notification were discussed in CY 2020 Medicare Physician Fee Schedule (MPFS) rulemaking. This CR updates the therapy code list and associated policies for CY 2020, as follows:

    For CY 2020, the CPT Editorial Panel created two new biofeedback codes to replace CPT code 90911. CMS designated them as “sometimes therapy” to permit physicians and Non-Physician Practitioners (NPPs), including nurse practitioners, physicians assistants, and certified nurse specialist to furnish these services outside a therapy plan of care when appropriate. The two new “sometimes therapy” codes using 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)

    The CPT Editorial Panel also created, for CY 2020, CPT code 97129 and 97130 to replace CPT code 97127, which CMS did not recognize. These new codes will effectively replace Healthcare Common Procedure Coding System (HCPCS) code G0515 which is deleted, effective January 1, 2020. These codes are designated “sometimes therapy” in order to permit physicians, NPPs, and psychologists to furnish these services outside a therapy plan of care when appropriate. The CPT long descriptors for the two new “sometimes therapy” codes, are as follows:

    • CPT 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 97130 - 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; each additional 15 minutes (List separately in addition to code for primary procedure)

    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

    These codes were used for Functional Reporting of therapy services for CY 2013 through 2018, but were retained for CY 2019 as discussed in CY 2019 MPFS final rule at 83 FR 59661.

    CPT codes 0019T and 64550 are being removed from prior years, 2017 and 2019, respectively.

    Reference

    Centers for Medicare & Medicaid Services

    Transmittal 10241


  • Therapy Codes Update

    26 May 2020 11:49 AM | Zachary Edgar (Administrator)

    Issue Date: 5/26/2020

    Effective Date: 6/16/2020

    This article informs you of updates to the list of codes that sometimes or always describe therapy services. The additions to the therapy code list reflect those made in the Calendar Year (CY) 2020 for the COVID-19 Public Health Emergency (PHE). Please make sure your billing staffs are aware of these changes.

    CMS is designating the below listed codes we’ve collectively termed as Communications Technology-Based Services (CTBS) as “sometimes therapy,” to permit physicians and NonPhysician Practitioners (NPPs), including nurse practitioners, physician assistants, and clinical nurse specialists to provide these services outside a therapy plan of care when appropriate. When provided by psychologists, licensed clinical social workers, or other practitioners, these CTBS codes are never considered therapy services and may not be reported with a GN, GO, or GP therapy modifier. When provided by therapists in private practice or therapists in institutional providers of therapy services, the CTBS codes are always provided under a physical therapy, occupational therapy, or speech-language pathology plan of care and must be reported with the associated GP, GO, or GN therapy modifier.

    These three CPT codes, with their short descriptors, are added for telephone assessment and management services:

    • CPT code 98966 (Hc pro phone call 5-10 min)

    • CPT code 98967 (Hc pro phone call 11-20 min)

    • CPT code 98968 (Hc pro phone call 21-30 min)

    These five HCPCS codes, with their short descriptors, are added for remote evaluation of patient images/video, virtual check-ins, and online assessments (e-visits):

    • HCPCS code G2010 (Remot image submit by pt)

    • HCPCS code G2012 (Brief check in by MD/QHP)

    • HCPCS code G2061 (Qual nonMD est pt 5-10 min)

    • HCPCS code G2062 (Qual nonMD est pt 11-20 min) • HCPCS code G2063 (Qual nonMD est pt 21 min)

    Reference

    Centers for Medicare and Medicaid

    MLN Matters Number: MM11791


  • The Role of Therapy under the Home Health Patient-Driven Groupings Model (PDGM)

    10 Feb 2020 11:35 AM | Zachary Edgar (Administrator)

    Issue Date: 2/10/2020

    Effective Date: January 1, 2020

    This special edition MLN Matters article is for home health agencies (HHAs) that furnish therapy services (physical therapy, occupational therapy, and speech-language pathology therapy) under a physician-established Medicare home health plan of care.

    Background

    The Bipartisan Budget Act of 2018 (BBA of 2018) included several requirements for home health payment reform, effective January 1, 2020. These requirements include the elimination of the use of therapy thresholds for case-mix adjustment and a change from a 60-day unit of payment to a 30-day unit of payment. The mandated home health payment reform resulted in the Patient-Driven Groupings Model, or PDGM. The PDGM is designed to emphasize clinical characteristics and other patient information to better align Medicare payments with patients’ care needs.

    The Continued Role of Therapy Under the PDGM

    The need for therapy services under PDGM remains unchanged. Therapy provision should be determined by the individual needs of the patient without restriction or limitation on the types of disciplines provided or the frequency or duration of visits. The number of needed visits to achieve the goals outlined on the plan of care is determined through the therapist’s assessment of the patient in collaboration with the physician responsible for the home health plan of care. The home health Conditions of Participation (CoPs) (42 CFR 484.60) require that each patient must receive an individualized written plan of care. The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment, including identification of the responsible discipline(s); the measurable outcomes that the HHA anticipates will occur as a result of implementing and coordinating the plan of care, and the patient and caregiver education and training. All services must be furnished in accordance with physician orders and accepted standards of practice. Therefore, the visit patterns of therapists should not be altered without consultation and agreement from the physician responsible for the home health plan of care. Any changes to the frequency or duration of therapy visits must be in accordance with the home health CoPs at 42 CFR 484.60.

    Additionally, beneficiaries must receive proper written notice in advance of the HHA reducing or terminating on-going care in accordance with the home health CoPs regarding patient rights at 42 CFR 484.50. These rights also include that the patient must be advised of the name, address, and telephone number of the Quality Improvement Organization (QIO) in the beneficiary’s service area if the beneficiary has a complaint about the quality of care he/she has received, or if the beneficiary needs to appeal a health care provider’s decision to discontinue services.

    Even though therapy thresholds are no longer a factor in adjusting home health payment, there are two clinical groups under the PDGM where the primary reason for home health services is for therapy (musculoskeletal rehabilitation and neuro/stroke rehabilitation). Furthermore, therapy should be provided regardless of the clinical group when included under the plan of care. While the principal diagnosis helps define the primary reason for home health services, it does not in any way direct what services should be included in the plan of care. Additionally, there is no improvement standard under the Medicare home health benefit and therapy services can be provided for restorative or maintenance purposes. The physician who establishes and periodically reviews the home health plan of care must determine the therapy the patient needs regardless of the patient’s diagnoses or PDGM clinical group.

    Therapists play an instrumental role in assessing and documenting patients’ functional Therapists play an instrumental role in assessing and documenting patients’ functional impairments. This information is captured through responses to OASIS items measuring functional ability, including walking, dressing and bathing and assists therapists in developing an individualized home health therapy plan of care in collaboration with the certifying physician. A comprehensive assessment conducted by a skilled therapist can help to ensure that patient needs are identified, an individualized therapy plan of care is established, therapy services are provided, and goals of care are met.

    Finally, the quality scores on Home Health Compare incorporate the use of therapy services in patient outcomes. Home Health Compare is a website for patients and their families where they can compare HHAs to help them choose a quality HHA that has the skilled home health services they need. In addition to general information about HHAs, Home Health Compare includes information on:

    • Services offered (like nursing care, physical therapy, occupational therapy, speech therapy, medical/social services, and home health aide services )
    • A Quality of Patient Care star rating that summarizes selected information about the performance of each home health agency compared to other agencies
    • Information about each home health agency’s quality of care (quality measures) and information from patients about experiences with the home health agency (patient survey results)

    Reference

    Centers for Medicare and Medicaid

    MLN Matters Number: SE20005

  • 2020 Annual Update to the Therapy Code List

    28 Jan 2020 1:45 PM | Zachary Edgar (Administrator)

    Effective Date: January 1, 2020

    Applicable Providers

    Physicians, therapists, and suppliers billing Medicare Administrative Contractors (MACs) for therapy services provided to Medicare beneficiaries.

    Coding Changes

    CR 11501 updates the list of codes that sometimes or always describe therapy services. The additions, changes, and deletions to the therapy code list reflect those made in the Calendar Year (CY) 2020 Current Procedural Terminology (CPT) and Level II HCPCS.

    Biofeedback

    The CPT Editorial Panel created two new biofeedback codes to replace CPT code 90911. The Centers for Medicare & Medicaid Services (CMS) designated these new codes as “sometimes therapy” to permit physicians and Non-Physician Practitioners (NPPs), including nurse practitioners, physician assistants, and certified nurse specialists to furnish these services outside a therapy plan of care when appropriate. 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)

    Therapeutic Interventions

    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. The CPT long descriptors for the two new “sometimes therapy” codes are:

    • 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

    These codes were used for Functional Reporting of therapy services for CY 2013 through 2018 but were retained for CY 2019 as discussed in the CY 2019 MPFS final rule at 83 FR 59661.

  • Manual Updates Related to Calendar Year (CY) 2020 Home Health Payment Policy Changes, Maintenance Therapy, and Remote Patient Monitoring

    10 Jan 2020 11:50 AM | Zachary Edgar (Administrator)

    Issue Date: 1/10/2020

    Effective Date: 2/11/2020

    Provider Action Needed

    CR11577 updates Chapter 7 of the Medicare Benefit Policy Manual to reflect policy changes finalized in the Calendar Year (CY) 2019 and 2020 Home Health Prospective Payment System (HH PPS) Final Rules with comment period (83 FR 56406 and 84 FR 60478). Specifically, these manual updates reflect policies related to:

    • The implementation of the Patient-Driven Groupings Model (PDGM)
    • A change to a 30-day unit of payment
    • Changes to split-percentage payments
    • Changes to the provision of maintenance therapy
    • The definition of remote patient monitoring.

    Background

    Regulations at 42 Code of Federal Regulations (CFR) 484.205 set forth the basis of home health payment under the HH PPS. Currently, Home Health Agencies (HHAs) are paid a prospective payment for a 60-day episode of care, adjusted for case-mix and area wage differences. Based on Section 51001 of the Bipartisan Budget Act of 2018, the Centers for Medicare & Medicaid Services (CMS) finalized policy changes to the home health unit of payment and the case-mix adjustment methodology in the CY 2019 HH PPS final rule with comment period (83 FR 56406), effective for home health periods of care beginning on and after January 1, 2020.

    Also, in the CY 2019 HH PPS final rule with comment period, CMS finalized a change in the unit of payment from 60-day episodes to 30-day periods for periods beginning on or after January 1, 2020. This 30-day payment amount is adjusted by a new case-mix adjustment methodology, the Patient-Driven Groupings Model (PDGM), also finalized in the CY 2019 HH PPS final rule. Payment under the PDGM is adjusted by patient characteristics and other information obtained from home health claims, other Medicare claims, and certain items from the Outcome and Assessment Information Item Set (OASIS). Specifically, home health 30-day payments will be adjusted by the principal and secondary diagnoses, timing of the period of care, admission source and level of functional impairment.

    In the CY 2020 HH PPS final rule with comment period (84 FR 60578), CMS finalized a change to the split-percentage payment approach, reducing the up-front payment amount to 20 percent in CY 2020 for all 30-day periods of care for HHAs certified for participation in Medicare on or before December 31, 2018. HHAs will submit a Request for Anticipated Payment (RAP) at the beginning of each 30-day period and a final claim at the end of each 30-day period.

    As finalized in the CY 2019 HH PPS final rule (83 FR 56406), newly enrolled HHAs (that is, HHAs certified for participation in Medicare on and after January 1, 2019) will not receive splitpercentage payments for 30-day periods beginning on or after January 1, 2020. Newly enrolled HHAs will submit a “no-pay” RAP at the beginning of each 30-day period to establish the home health period of care and trigger consolidated billing edits in the Medicare claims processing system. Newly enrolled HHAs will receive a full 30-day period payment rate (minus any adjustments) after submission of a final claim at the end of each 30-day period.

    The manual revisions related to these changes are in Section 10 of the revised Chapter 7 as included in CR11577.

    In the CY 2020 HH PPS final rule with comment period (84 FR 60578), CMS finalized changes to the regulations at 42 CFR 409.44(c)(2)(iii)(C) regarding the provision of maintenance therapy services. Beginning in CY 2020, therapist assistants, and not just qualified therapists, can perform maintenance therapy under the Medicare home health benefit in accordance with individual state practice requirements.

    The manual revisions related to these therapy services are in Section 40.2.1 of the revised Chapter 7.

    Section 1895(e)(1)(A) of the Social Security Act (the Act) prohibits payments for services furnished via a telecommunications system if such services substitute for in-person home health services ordered as part of a plan of care. However, the statute does not define the term, “telecommunications system” as it relates to the provision of home health care. In CY 2019 HH PPS final rule with comment period (83 FR 56406), CMS defined “remote patient monitoring,” and finalized associated changes regarding allowed administrative costs on Medicare cost reports.

    CMS defined remote patient monitoring under the Medicare home health benefit as, “the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient or caregiver or both to the home health agency.” This definition is in Section 80.10 of the revised Chapter 7. Visits to a beneficiary’s home for the sole purpose of supplying, connecting, and/or training the patient on the remote patient monitoring equipment, without the provision of another skilled service, are not separately billable. CMS also finalized to amend the regulations at 42 CFR 409.46 to include the costs of remote patient monitoring as an allowable administrative cost (that is, operating expense), if remote patient monitoring is used by the HHA to augment the care planning process. These remote monitoring changes are also in the revised Section 80.10.

    Reference

    Centers for Medicare and Medicaid

    MLN Matters MM11577


  • New Modifiers to Identify Occupational Therapy (OT) and Physical Therapy (PT) Services Provided by a Therapy Assistant

    1 Nov 2019 1:40 PM | Zachary Edgar (Administrator)

    Effective Date: January 1, 2020

    Applicable Providers

    Physical and occupational therapists and assistants.

    Compliance Change

    CMS has established two modifiers, CQ and CO, for services furnished in whole or in part by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs). The modifiers are defined as follows:

    •  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

    Effective for claims with dates of service on and after January 1, 2020, the CQ and CO modifiers are required to be used, when applicable, for services furnished in whole or in part by PTAs and OTAs on the claim line of the service alongside the respective GP or GO therapy modifier, to identify those PTA and OTA services furnished under a PT or OT plan of care.

    For those practitioners submitting professional claims who are paid under the PFS, the CQ/CO modifiers apply only to services of physical and occupational therapists in private practice (PTPPs and OTPPs); and not to the therapy services furnished by or incident to the services of physicians or nonphysician practitioners (NPPs) ‒ including nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs) ‒ because PTAs and OTAs do not meet the qualifications and standards of physical or occupational therapists, as required by §§ 410.60 and 410.59, respectively.

    For providers submitting institutional claims and paid at PFS rates for their outpatient PT and OT services, the CQ and CO modifiers apply to the following providers: outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and CORFs. However, the CQ and CO modifiers are not applicable to claims from critical access hospitals because they are paid on a reasonable cost basis, or from other providers for which payment for OT services is not made under the PFS rates. The CQ modifier must be paired to the GP therapy modifier and the CO modifier with the GO therapy modifier. Claims not so paired will be rejected/returned as unprocessable.

  • Policies for Negative Pressure Wound Therapy (NPWT) Using a Disposable Device

    11 Jun 2019 1:42 PM | Zachary Edgar (Administrator)

    Article Release Date: June 11, 2019

    Applicable Providers

    Therapists and Home Health Agencies (HHAs) submitting claims to Home Health & Hospice Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

    Reporting NPWT Services using a Disposable Device

    Effective January 1, 2017, Medicare makes a separate payment amount for a disposable Negative Pressure Wound Therapy (NPWT) device for a patient under a home health plan of care. Payment is equal to the amount of the payment that would otherwise be made under the Outpatient Prospective Payment System (OPPS).

    Disposable NPWT services are billed using the following Current Procedural Terminology® (CPT) codes:

    • 97607 - Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or equal to 50 square centimeters.
    •  97608 - Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area greater than 50 square centimeters.

    The HHA reports the CPT code with one of three revenue codes, depending on the practitioner that provided the service:

    • Skilled nurse – 0559
    • Physical therapist – 042x
    • Occupational therapy – 043x.

    When using revenue codes 042x or 043x, the HHA should not use the therapy plan of care modifiers (GO or GP) for NPWT services.

    There are no additional documentation requirements for the provision of NPWT using a disposable device. The HHA documentation (and any supporting documentation leading to the order for home health and NPWT using a disposable device) should support that the patient needs wound care using NPWT. The medical necessity and documentation requirements would be no different than what is currently required when patients receive wound care from a home health nurse when the patient is receiving conventional NPWT. HHAs may also follow their own internal policies and procedures for documenting clinical information in the patient’s medical record beyond those required by regulation.

    Billing for NPWT Services:

    The (CPT) codes for furnishing NPWT using a disposable device include both performing the service and the disposable NPWT device, which is defined as an integrated system comprised of a non-manual vacuum pump, a receptacle for collecting exudate, and dressings for the purposes of wound therapy. Services related to the furnishing NPWT using a disposable device that do not encompass the placement or replacement of the entire integrated system should be billed per existing HH PPS guidelines.

    When furnishing NPWT using a disposable device, both the device and the services associated with furnishing the device are paid for separately based on the OPPS amount.

    When a HHA furnishes NPWT using a disposable device, the HHA is furnishing a new disposable NPWT device.

    • This means the HHA provider is either initially applying an entirely new disposable NPWT device, or removing a disposable NPWT device and replacing it with an entirely new one.
    • In both cases, all the services associated with NPWT—for example, conducting a wound assessment, changing dressings, and providing instructions for ongoing care—must be reported on TOB 34x with the corresponding CPT code (that is, CPT® code 97607 or 97608); they may not be reported on the home health claim (TOB 32x).
    • The reimbursement for all of these services is included in the OPPS reimbursement amount for those two CPT codes.

    Any follow-up visits for wound assessment, wound management, and dressing changes where a new disposable NPWT device is not applied must be included on the home health claim (TOB 32x).


About Us

Therapy Comply is a healthcare compliance firm that seeks to bring high quality web-based compliance guidance and one-on-one consulting services to small and medium size physical, occupational, and speech therapy practices.

Learn More 

Join Us

Join today as either a monthly or a yearly member and enjoy full access to the site and a significant discount to our live and recorded webinars.  Members also have access to compliance and billing support.

Join Today 

Find Us


Powered by Wild Apricot Membership Software