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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

  • 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).


  • Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018

    25 Jan 2019 2:53 PM | Zachary Edgar (Administrator)

    Effective Date: 2/26/2019

    This update is intended for therapists, physicians, certain nonphysician practitioners and other providers of therapy services – including physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services − who submit professional or institutional claims to Medicare Administrative Contractors (MACs) for therapy services provided to Medicare beneficiaries.

    CR 11120 updates both the Medicare Benefit Policy Manual and Medicare Claims Processing Manual to reflect recent changes in outpatient therapy services billing instructions and payment policies related to the Bipartisan Budget Act of 2018 and the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule. These policy revisions include:

    • The repeal of the application of the outpatient therapy caps and the retention of the therapy cap amounts as thresholds of incurred expenses above which claims must include a modifier to confirm services are medically necessary as shown by medical record documentation; and,
    • The discontinuation of the functional reporting requirements.

    Background

    Section 50202 of the Bipartisan Budget Act of 2018 (BBA of 2018) repeals application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold of incurred expenses above which claims must include a KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.

    After a consideration of stakeholders’ requests for burden reduction and a review of the Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA) requirements, the Centers for Medicare & Medicaid Services (CMS) concluded in the CY 2019 MPFS final rule that continued collection of functional reporting data through the same format would not yield additional information to inform future analyses. The rule ended the functional reporting requirements to reduce burden of reporting for providers of therapy services.

    CR 11120 updates Chapters 12 and 15 of the Medicare Benefit Policy Manual and Chapter 5 of the Medicare Claims Policy Manual to reflect these changes to law and regulation. Note: The relevant manual chapters are attached to CR 11120 for your review.

    Effective for dates of service on or after January 1, 2018, providers of therapy services shall continue to report the KX modifier on claims as applicable. The modifier no longer represents an exception request but serves as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record after the beneficiary has exceeded the threshold of incurred expenses.

    Effective for dates of service on or after January 1, 2019, HCPCS G-codes and severity modifiers for functional reporting are no longer required on claims for therapy services.

    Reference

    MLN Matters MM11120

  • Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018

    25 Jan 2019 1:38 PM | Zachary Edgar (Administrator)

    Effective Date: January 1, 2019

    Applicable Providers

    Therapists, physicians, certain non-physician practitioners and other providers of therapy services – including physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services − who submit professional or institutional claims to Medicare Administrative Contractors (MACs) for therapy services provided to Medicare beneficiaries

    Compliance Change

    CR 11120 updates both the Medicare Benefit Policy Manual and Medicare Claims Processing Manual to reflect recent changes in outpatient therapy services billing instructions and payment policies related to the Bipartisan Budget Act of 2018 and the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule.

    These policy revisions include:

    • The repeal of the application of the outpatient therapy caps and the retention of the therapy cap amounts as thresholds of incurred expenses above which claims must include a modifier to confirm services are medically necessary as shown by medical record documentation; and,
    • The discontinuation of the functional reporting requirements. Please make sure your billing staffs are aware of these changes.

    Effective for dates of service on or after January 1, 2018, providers of therapy services shall continue to report the KX modifier on claims as applicable. The modifier no longer represents an exception request but serves as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record after the beneficiary has exceeded the threshold of incurred expenses. Effective for dates of service on or after January 1, 2019, HCPCS G-codes and severity modifiers for functional reporting are no longer required on claims for therapy services.

    Background Information

    Section 50202 of the Bipartisan Budget Act of 2018 (BBA of 2018) repeals application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold of incurred expenses above which claims must include a KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.

    After a consideration of stakeholders’ requests for burden reduction and a review of the Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA) requirements, the Centers for Medicare & Medicaid Services (CMS) concluded in the CY 2019 MPFS final rule that continued collection of functional reporting data through the same format would not yield additional information to inform future analyses. The rule ended the functional reporting requirements to reduce burden of reporting for providers of therapy services.


  • Annual Update to the Per-Beneficiary Therapy Amounts

    30 Nov 2018 12:12 PM | Zachary Edgar (Administrator)

    Effective Date: 1/7/2019

    This update is intended for physicians, therapists, and other providers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.

    CR 11055 describes the annual per-beneficiary incurred expense amounts now known as the KX modifier thresholds, and related policy updates for CY 2019. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed when the Bipartisan Budget Act of 2018 (BBA of 2018) was signed into law. Another provision of the BBA of 2018 lowers the threshold of the targeted medical review process as explained in the Background section below.

    For CY 2019, the KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined is $2,040. For occupational therapy (OT) services, the CY 2019 threshold amount is $2,040. Make sure that your billing staffs are aware of these updates.

    Background

    Effective for January 1, 2018, section 50202 of the Bipartisan Budget Act of 2018, P.L. 115-123 (BBA of 2018) amended section 1833(g) of the Social Security Act (the Act) to repeal the application of the therapy caps and the therapy caps exceptions process while also retaining and adding limitations to ensure appropriate therapy. The therapy caps or financial limitations originally applied through section 4541(c) of the Balanced Budget Act of 1997, P.L. 105-33 (1997 BBA) are no longer applicable to beneficiaries.

    A separate provision of section 50202 of the BBA of 2018 adds section 1833(g)(7)(A) of the Act to preserve the former therapy cap amounts as thresholds above which claims must include the KX modifier to confirm that services are medically necessary as justified by appropriate documentation in the medical record. Claims from suppliers or providers for therapy services above these amounts without the KX modifier are denied. These amounts are now known as the KX modifier thresholds.

    Just as with the incurred expenses for the therapy cap amounts, there is one KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined and a separate amount for occupational therapy (OT) services. These perbeneficiary amounts under section 1833(g) of the Act (as amended by 1997 BBA) are updated each year by the Medicare Economic Index (MEI).

    For CY 2019, the KX modifier threshold amounts are: (a) $2,040 for PT and SLP services combined, and (b) $2,040 for OT services.

    Another provision of section 50202 of the BBA of 2018 adds section 1833(g)(7)(B) of the Act which maintains the targeted medical review process (first established through section 202 of the Medicare Access and CHIP Reauthorization Act of 2015), but at a lower threshold than the $3,700 amount established as part of the therapy caps exceptions process via section 3005 of the Middle Class Tax Relief and Jobs Creation Act of 2012. For CY 2018 (and each successive calendar year until 2028, at which time it is indexed annually by the MEI), this now-termed Medical Review (MR) threshold amount is $3,000 for PT and SLP services combined and $3,000 for OT services.

    Reference

    MLN Matters Number: MM11055


  • 2019 Update to the Per-Beneficiary Therapy Amounts

    30 Nov 2018 10:57 AM | Zachary Edgar (Administrator)

    Effective Date: January 1, 2019

    Applicable Providers

    Physicians, therapists, and other providers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.

    Compliance Change

    For CY 2019, the KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined is $2,040. For occupational therapy (OT) services, the CY 2019 threshold amount is $2,040.

    The annual per-beneficiary incurred expense amounts now known as the KX modifier thresholds, and related policy updates for CY 2019. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed when the Bipartisan Budget Act of 2018 (BBA of 2018) was signed into law.

    Reference

    MLN Matters Number: MM11055


  • Modifications Within Common Working File (CWF) to Adjustment Claims Exceeding Annual Therapy Threshold

    10 Aug 2018 12:10 PM | Zachary Edgar (Administrator)

    Effective Date: 1/7/2019

    The purpose of this Change Request (CR) is for CWF to modify the process to set CWF edits correctly on adjustment claims when the therapy threshold is exceeded.

    Background: Currently, when CWF receives an adjustment to a therapy (physical-PT, speech-SP, or occupational-OT) claim which had been paid prior to the therapy cap being reached, CWF searches to see if the beneficiary exceeded the threshold. If the beneficiary exceeds the threshold then CWF subjects the adjustment claim(s) to the normal therapy threshold processing, and if no 'KX' modifier is present, rejects the adjustment claim(s) and generates an edit which ultimately results in the original claim being treated as an overpayment.

    The CMS request CWF to review CR 8938 and ensure that the system is in compliance with the therapy adjustment requirements and modify/revise the software if when necessary.

    The contractor shall ensure that the adjustments to therapy claims for PT/SP and/or OT service(s) are excluded from therapy edits and threshold limits

    Reference

    Transmittal # R2111OTN


  • Clarification of Instructions Regarding the Intensive Level of Rehabilitation Therapy Services Requirements

    23 Feb 2018 11:59 AM | Zachary Edgar (Administrator)

    Effective Date: 3/23/2018

    The purpose of this Change Request (CR) is to clarify the instructions for conducting medical review of Inpatient Rehabilitation Facility (IRF) claims when reviewing the requirements for the intensive level of rehabilitation therapy services.

    Contractors shall verify that the IRF documentation requirements are met in accordance with Pub 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.

    Contractors shall not make denials based solely on any threshold of therapy time.

    Contractors shall use clinical review judgment to determine medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of the case.

    Contractors shall not make denials solely because the situation/rationale that justifies group therapy is not specified in the patient’s medical records at the IRF.

    Reference

    Transmittal #R771PI

  • 2018 Annual Update to the Therapy Code List

    16 Nov 2017 11:40 AM | Zachary Edgar (Administrator)

    Effective Date: 1/2/2018

    This update is intended for physicians, therapists, and other providers, including Comprehensive Outpatient Rehabilitation Facilities (CORFs), submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.

    Change Request (CR) 10303 updates the list of codes that sometimes or always describe therapy services and their associated policies. The additions, changes, and deletions to the therapy code list reflect those made in the Calendar Year (CY) 2018 Healthcare Common Procedure Coding System and Current Procedural Terminology, Fourth Edition (HCPCS/CPT4). The therapy code listing is available at http://www.cms.gov/Medicare/Billing/TherapyServices/index.html

    Background

    The Social Security Act (Section 1834(k)(5)) requires that all claims for outpatient rehabilitation therapy services and all Comprehensive Outpatient Rehabilitation Facility (CORF) services be reported using a uniform coding system. The Calendar Year (CY) 2018 Healthcare Common Procedure Coding System and Current Procedural Terminology, Fourth Edition (HCPCS/CPT-4) is the coding system used for the reporting of these services.

    The policies implemented in CR10303 were discussed in CY 2018 Medicare Physician Fee Schedule (MPFS) rulemaking. CR10303 updates the therapy code list and associated policies for CY 2018, as follows:

    The Current Procedural Terminology (CPT) Editorial Panel revised the set of codes physical and occupational therapists use to report orthotic and prosthetic management and training services by differentiating between initial and subsequent encounters through the: (a) addition of the term “initial encounter” to the code descriptors for CPT codes 97760 and 97761, (b) creation of CPT code 97763 to describe all subsequent encounters for orthotics and/or prosthetics management and training services, and (c) deletion of CPT code 97762. The new long descriptors for CPT codes 97760 and 97761 – now intended only to be reported for the initial encounter with the patient – are:

    • CPT code 97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes)
    • CPT code 97761 (Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes)

    The Centers for Medicare & Medicaid Services (CMS) will add CPT code 97763 to the therapy code list and CPT code 97762 will be deleted.

    The panel also created, for CY 2018, CPT code 97127 to replace/delete CPT code 97532. CMS will recognize HCPCS code G0515, instead of CPT code 97127, and add HCPCS code G0515 to the therapy code list. CPT code 97127 will be assigned a Medicare Physician Fee Schedule (MPFS) payment status indicator of “I” to indicate that it is “invalid” for Medicare purposes and that another code is used for reporting and payment for these services.

    Just as its predecessor code was, CPT code 97763 is designated as “always therapy” and must always be reported with the appropriate therapy modifier, GN, GO or GP, to indicate whether it’s under a Speech-language pathology (SLP), Occupational Therapy (OT) or Physical Therapy (PT) plan of care, respectively.

     HCPCS code G0515 is designated as a “sometimes therapy” code, which means that an appropriate therapy modifier − GN, GO or GP, to reflect it’s under an SLP, OT, or PT plan of care – is always required when this service is furnished by therapists; and, when it’s furnished by or incident to physicians and certain Nonphysician Practitioners (NPPs), that is, nurse practitioners, physician assistants, and clinical nurse specialists when the services are integral to an SLP, OT, or PT plan of care. Accordingly, HCPCS code G0515 is sometimes appropriately reported by physicians, NPPs, and psychologists without a therapy modifier when it is appropriately furnished outside an SLP, OT, or PT plan of care. When furnished by psychologists, the services of HCPCS code G0515 are never considered therapy services and may not be reported with a GN, GO, or GP therapy modifier.

    The therapy code list is updated with one new “always therapy” code and one new “sometimes therapy” code, using their HCPCS/CPT long descriptors, as follows:

    • CPT code 97763 – This “always therapy” code replaces/deletes CPT code 97762. o CPT code 97763: Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes
    • HCPCS code G0515 – This “sometimes therapy” code replaces/deletes CPT code 97532.
    • HCPCS code G0515: Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

    Reference

    MLN Matters MM10303


About Us

Zachary Edgar JD, LLM is the managing partner for Therapy Comply.  Zachary is a healthcare attorney that specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

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