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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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Medicare Updates

  • 2022 KX Modifier and Targeted Review

    1 Dec 2021 2:42 PM | Zachary Edgar (Administrator)

    2022 KX threshold amount: $2,150 for PT and SLP services combined.

    2022 KX threshold amount: $2,150 for OT services.

    The KX modifier applies to all Part B outpatient therapy settings and providers including:

    • Therapists’ Private Practices;
    • Offices of Physicians and NPPs;
    • Part B Skilled Nursing Facilities;
    • Home Health Agencies;
    • Rehabilitation Agencies (also known as ORFs);
    • Comprehensive Outpatient Rehab Facilities;
    • Outpatient Hospital Departments; and
    • Critical Access Hospitals.

      By using the KX modifier on the claim, the therapy supplier or provider is attesting that the services are medically necessary, and that supportive justification is documented in the medical record.

      The threshold is based on the incurred expanses made for the patient’s outpatient therapy services.  It does not matter if therapy services are provided by one therapist or multiple therapists.   

      Claims for outpatient therapy services incurred above the threshold amounts without the KX modifier will be denied.  Must be appended to all claims filed after the threshold amount has been reached.   

      Targeted Medical Review

      The BBA of 2018 retains the targeted medical review (MR) process but at a lower threshold amount of $3,000. For CY 2022 (and each calendar year until 2028 at which time it is indexed annually by the MEI), the MR threshold is $3,000 for PT and SLP services and $3,000 for OT services.

      To prevent improper payments, Medicare contractors operate the medical review program. Medical reviews involve the collection and clinical review of medical records and related information to ensure that payment is made only for services that meet all Medicare coverage, coding, billing, and medical necessity requirements.

      Therapists can check the amount of expenses that have been made year to date (YTD) for the patient on the MAC websites:

      CGS - First Coast - National Government Services - Noridian - Novitas - Palmetto - WPS

    • Reduced Payment for Physical Therapy and Occupational Therapy Services Furnished In Whole or In Part by a Physical Therapist Assistant (PTA) or Occupational Therapy Assistant (OTA)

      22 Nov 2021 12:21 PM | Zachary Edgar (Administrator)

      Issue Date: 11/22/21

      Effective Date: 1/3/22

      This MLN Matters Article is for physical and occupational therapists and therapy providers billing Medicare administrative Contractors (MACs) for services of physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) provided to Medicare patients.

      Section 53107 of the BBA of 2018 added section 1834(v) to the Social Security Act that requires CMS, through the use of new modifiers, to reduce the payment for physical and occupational therapy services provided in whole or in part by PTAs or OTAs. We’ll make the reduced payment at 85% of the otherwise applicable Part B payment amount. This reduced payment applies to dates of service on and after January 1, 2022.

      The reduced PFS payment affects physical therapists (PTs) in private practice (PTPPs) and occupational therapists (OTs) in private practice (OTPPs), including PTPPs and OTPPs who have reassigned their benefits to physician groups or to groups of certain nonphysician practitioners (NPPs), including physician assistants, nurse practitioners and clinical nurse specialists when the PTPP/OTPP National Provider Identifier (NPI) appears as the rendering provider on the claim.

      The reduced PFS payment for PTA/OTA services also applies to institutional therapy providers, including comprehensive outpatient rehabilitation facilities, with the exception of critical access hospitals and other providers that aren’t paid using Medicare Physician Fee Schedule (MPFS). This payment policy is applicable to the following bill types: 12X, 13X, 22X, 23X, 34X, 74X, and 75X.

      In the CY 2019 final rule (83 FR 59654 through 59660), we created 2 new modifiers for the services that PTAs/OTAs provide. We have required the CQ/CO modifiers on claims, alongside the GP/GO therapy modifiers ─ which are used to indicate the services are furnished under a physical therapy or occupational therapy plan of care, respectively ─ from PTPPs, OTPPs, and therapy providers for services furnished in whole or in part by PTAs/OTAs for dates of service on or after January 1, 2020. They are:

      • CQ: Outpatient physical therapy services provided in whole or in part by a physical therapist assistant
      • CO: Outpatient occupational therapy services provided in whole or in part by an occupational therapy assistant

      In that CY 2019 PFS final rule, we also finalized a de minimis standard under which a service is considered to be furnished in whole or in part by a PTA or OTA when more than 10 percent of a service – whether timed or untimed ─ is furnished by the PTA or OTA.

      In the CY 2020 final rule (84 FR 62702 through 62708), we finalized applications of the de minimis standard that requires the CQ/CO modifier to be on claims when the PTA/OTA, independent of the PT/OT, provides:

      • More than 10% of an untimed service or
      • More than 10% of a 15-minute timed unit of service

      We required the CQ/CO modifiers beginning with claims for dates of service on and after January 1, 2020.

      In the CY 2022 final rule (86 FR 65169 through 65177), we finalized a de minimis policy that requires the CQ/CO modifier to be on claims when the PTA/OTA provides more than 10% of a unit of service for other time intervals than the 15-minute one. This includes the 20-minute time increment of the new codes for remote therapeutic monitoring (RTM) services.

      Also, during PFS rulemaking for CY 2022, in response to concerns raised by stakeholders and to promote appropriate care, we finalized a policy for which the de minimis standard is not applicable. Specifically, we finalized rules for applying the CQ/CO modifiers by introducing the midpoint rule, also known as the “8-minute rule,” in which the PT/OT provides at least 8 minutes (more than half, or 7.5 minutes, of the 15-minute unit). In these cases, the PT/OT bills the final unit of a multi-unit scenario without the CQ/CO modifier.

      We also defined a limited number of cases in which there are 2 units left to bill in which you bill one 15-minute unit with the CQ/CO modifier and the other 15-minute unit without it. These cases include scenarios in which the PT/OT and the PTA/OTA each provide between 9 and 14 minutes of a 15-minute timed service when the total time of therapy services provided in combination by the PT/OT and PTA/OTA is at least 23 minutes, but no more than 28 minutes.

      We also finalized the following policies, where the CQ/CO modifiers do apply:

      •  Services wholly provided by PTAs and OTAs.
      •  In cases where one final 15-minute unit (of a multi-unit scenario) remains to be billed, the de minimis standard is applied to:
        • Services where the PTA/OTA provides 8 or more minutes of a 15-minute unit of service and the PT/OT provides less than 8 minutes – bill with the CQ/CO modifier as the de minimis standard is exceeded.
        • Services where both the PTA/OTA and the PT/OT each provide less than 8 minutes of a service – bill with the CQ/CO modifier if the minutes provided by the PTA/OTA exceed the de minimis standard.

      We finalized the below policies where the CQ/CO modifiers don’t apply:

      • When PTs and OTs wholly provide the services.
      • When a PT/OT and a PTA/OTA provide care to a patient at the same time the patient requires both providers – these scenarios show cases in which the assistant is helping the therapist to provide a highly skilled procedure or one in which both providers are needed for safety reasons.
      • When outpatient physical and occupational therapy services are provided by, or incident to, the services of physicians or certain nonphysician practitioners (NPPs). This is because therapy regulations require that the individual who does the therapy service incident to the service of a physician or NPP must meet the qualifications and standards for a therapist (other than state licensure).
      • In cases where there is 1 final 15-minute unit left to bill on a treatment day, the “8- minute rule” rule is applied when the PT/OT provides 8 or more minutes (the Medicare billing requirement for that final 15-minute service unit) – that final unit is billed without the CQ/CO modifier because the PT/OT provided enough minutes on their own (more than half) to report the service. Any minutes provided by the PTA/OTA are immaterial for purposes of billing.

      In cases where there are 2 units left to be billed, and the PT/OT and the PTA/OTA each provide between 9 and 14 minutes of a 15-minute timed service when the total time of therapy services provided by the PT/OT and PTA/OTA is at least 23 minutes, but no more than, 28 minutes:

      • Bill 1 unit without the CQ/CO modifier (for the unit the PT/OT provides), and
      • Bill 1 unit of the service with the CQ/CO modifier (for the unit provided by the PTA/OTA)

      Reference

      Centers for Medicare and Medicaid

      MLN Matters: MM12397


    • 2022 Medicare Parts A & B Premiums and Deductibles/2022 Medicare Part D Income-Related Monthly Adjustment Amounts

      12 Nov 2021 10:57 AM | Zachary Edgar (Administrator)

      On November 12, 2021, the Centers for Medicare & Medicaid Services (CMS) released the 2022 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs, and the 2022 Medicare Part D income-related monthly adjustment amounts.

      Medicare Part B Premium and Deductible

      Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A. 

      Each year the Medicare Part B premium, deductible, and coinsurance rates are determined according to the Social Security Act. The standard monthly premium for Medicare Part B enrollees will be $170.10 for 2022, an increase of $21.60 from $148.50 in 2021. The annual deductible for all Medicare Part B beneficiaries is $233 in 2022, an increase of $30 from the annual deductible of $203 in 2021.

      The increases in the 2022 Medicare Part B premium and deductible are due to:

      • Rising prices and utilization across the health care system that drive higher premiums year-over-year alongside anticipated increases in the intensity of care provided.
      • Congressional action to significantly lower the increase in the 2021 Medicare Part B premium, which resulted in the $3.00 per beneficiary per month increase in the Medicare Part B premium (that would have ended in 2021) being continued through 2025.
      • Additional contingency reserves due to the uncertainty regarding the potential use of the Alzheimer’s drug, Aduhelm™, by people with Medicare. In July 2021, CMS began a National Coverage Determination analysis process to determine whether and how Medicare will cover Aduhelm™ and similar drugs used to treat Alzheimer’s disease. As that process is still underway, there is uncertainty regarding the coverage and use of such drugs by Medicare beneficiaries in 2022. While the outcome of the coverage determination is unknown, our projection in no way implies what the coverage determination will be, however, we must plan for the possibility of coverage for this high cost Alzheimer’s drug which could, if covered, result in significantly higher expenditures for the Medicare program.

      Medicare Part B Income-Related Monthly Adjustment Amounts

      Since 2007, a beneficiary’s Part B monthly premium is based on his or her income. These income-related monthly adjustment amounts affect roughly 7 percent of people with Medicare Part B. The 2022 Part B total premiums for high-income beneficiaries are shown in the following table:

      Beneficiaries who file individual tax returns with modified adjusted gross income:

      Beneficiaries who file joint tax returns with modified adjusted gross income:

      Income-related monthly adjustment amount

      Total monthly premium amount

      Less than or equal to $91,000

      Less than or equal to $182,000

      $0.00

      $170.10

      Greater than $91,000 and less than or equal to $114,000

      Greater than $182,000 and less than or equal to $228,000

      $68.00

      $238.10

      Greater than $114,000 and less than or equal to $142,000

      Greater than $228,000 and less than or equal to $284,000

      $170.10

      $340.20

      Greater than $142,000 and less than or equal to $170,000

      Greater than $284,000 and less than or equal to $340,000

      $272.20

      $442.30

      Greater than $170,000 and less than $500,000

      Greater than $340,000 and less than $750,000

      $374.20

      $544.30

      Greater than or equal to $500,000

      Greater than or equal to $750,000

      $408.20

      $578.30

      Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

      Beneficiaries who are married and lived with their spouses at any time during the year, but who file separate tax returns from their spouses, with modified adjusted gross income:

      Income-related monthly adjustment amount

      Total monthly premium amount

      Less than or equal to $91,000

      $0.00

      $170.10

      Greater than $91,000 and less than $409,000

      $374.20

      $544.30

      Greater than or equal to $409,000

      $408.20

      $578.30

      Medicare Part A Premium and Deductible

      Medicare Part A covers inpatient hospital, skilled nursing facility, hospice, inpatient rehabilitation, and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

      The Medicare Part A inpatient hospital deductible that beneficiaries pay if admitted to the hospital will be $1,556 in 2022, an increase of $72 from $1,484 in 2021. The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. In 2022, beneficiaries must pay a coinsurance amount of $389 per day for the 61st through 90th day of a hospitalization ($371 in 2021) in a benefit period and $778 per day for lifetime reserve days ($742 in 2021). For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $194.50 in 2022 ($185.50 in 2021).

      Part A Deductible and Coinsurance Amounts for Calendar Years 2021 and 2022
      by Type of Cost Sharing

      2021

      2022

      Inpatient hospital deductible

      $1,484

      $1,556

      Daily coinsurance for 61st-90th Day

      $371

      $389

      Daily coinsurance for lifetime reserve days

      $742

      $778

      Skilled Nursing Facility coinsurance

      $185.50

      $194.50

      Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to voluntarily enroll in Medicare Part A. Individuals who had at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $274 in 2022, a $15 increase from 2021. Certain uninsured aged individuals who have less than 30 quarters of coverage and certain individuals with disabilities who have exhausted other entitlement will pay the full premium, which will be $499 a month in 2022, a $28 increase from 2021.

      Medicare Part D Income-Related Monthly Adjustment Amounts

      Since 2011, a beneficiary’s Part D monthly premium is based on his or her income. These income-related monthly adjustment amounts affect roughly 8 percent of people with Medicare Part D. These individuals will pay the income-related monthly adjustment amount in addition to their Part D premium. Part D premiums vary from plan to plan and roughly two-thirds are paid directly to the plan, with the remaining deducted from Social Security benefit checks. The Part D income-related monthly adjustment amounts are all deducted from Social Security benefit checks. The 2022 Part D income-related monthly adjustment amounts for high-income beneficiaries are shown in the following table:

      Beneficiaries who file individual tax returns with modified adjusted gross income

      Beneficiaries who file joint tax returns with modified adjusted gross income

      Income-related monthly adjustment amount

      Less than or equal to $91,000

      Less than or equal to $182,000

      $0.00

      Greater than $91,000 and less than or equal to $114,000

      Greater than $182,000 and less than or equal to $228,000

      $12.40

      Greater than $114,000 and less than or equal to $142,000

      Greater than $228,000 and less than or equal to $284,000

      $32.10

      Greater than $142,000 and less than or equal to $170,000

      Greater than $284,000 and less than or equal to $340,000

      $51.70

      Greater than $170,000 and less than $500,000

      Greater than $340,000 and less than $750,000

      $71.30

      Greater than or equal to $500,000

      Greater than or equal to $750,000

      $77.90

      Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

      Beneficiaries who are married and lived with their spouses at any time during the year, but file separate tax returns from their spouses, with modified adjusted gross income:

      Income-related monthly adjustment amount

      Less than or equal to $91,000

      $0.00

      Greater than $91,000 and less than $409,000

      $71.30

      Greater than or equal to $409,000

      $77.90

      Reference

      Centers for Medicare and Medicare.  2022 Medicare Parts A & B Premiums and Deductibles/2022 Medicare Part D Income-Related Monthly Adjustment Amounts.

      https://www.cms.gov/newsroom/fact-sheets/2022-medicare-parts-b-premiums-and-deductibles2022-medicare-part-d-income-related-monthly-adjustment


    • 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.

    About Us

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