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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

  • Therapy Cap Values for Calendar Year (CY) 2018

    9 Nov 2017 11:39 AM | Zachary Edgar (Administrator)

    Effective Date: 1/2/2018

    Change Request (CR) 10341 provides the amounts for outpatient therapy caps for Calendar Year (CY) 2018. For physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010. For occupational therapy, the CY 2018 cap is $2,010. Make sure that your billing staffs are aware of these therapy cap value updates.

    Background

    The Balanced Budget Act of 1997, P.L. 105-33, Section 4541(c) applies, per beneficiary, annual financial limitations on expenses considered incurred for outpatient therapy services under Medicare Part B, commonly referred to as “therapy caps.” The therapy caps are updated each year based on the Medicare Economic Index.

    Section 5107 of the Deficit Reduction Act of 2005 required an exceptions process to the therapy caps for reasonable and medically necessary services. The exceptions process for the therapy caps has been continuously extended several times through subsequent legislation. Most recently, Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended the therapy caps exceptions process through December 31, 2017.

    Reference

    MLN Matters MM10341


  • 2018 Update to the Per-Beneficiary Therapy Amounts

    9 Nov 2017 10:56 AM | Zachary Edgar (Administrator)

    Effective Date: January 1, 2018

    Applicable Providers

    Therapists, physicians, 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 physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010. For occupational therapy, the CY 2018 cap is $2,010. Make sure that your billing staffs are aware of these therapy cap value updates.

    Reference

    MLN Matters Number: MM10341

  • Updated Editing of Always Therapy Services – MCS

    27 Jul 2017 11:34 AM | Zachary Edgar (Administrator)

    Effective Date: 1/2/2018

    CR 10176 implements revised editing of Part B “Always Therapy” services to require the appropriate therapy modifier in order for the service to be accurately applied to the therapy cap. CR10176 contains no new policy. Instead, the guidelines presented in the CR improve the enforcement of longstanding, existing instructions. Make sure your billing staffs are aware of these revisions.

    Services furnished under the Outpatient Therapy (OPT) services benefit – including Speech Language Pathology (SLP), Occupational Therapy (OT), and Physical Therapy (PT) – are subject to the financial limitations, known as therapy caps, originally required under Section 4541 of the Balanced Budget Act (1997).

    There are two such caps. One cap is for PT and SLP services combined and another cap is for OT services. In order to accrue incurred expenses to the correct therapy cap; the use of one of the three therapy modifiers (GN, GO, or GP) is required on a certain set of Healthcare Common Procedure Coding System (HCPCS) codes in order to identify when each OPT service is furnished under an SLP, OT, or PT plan of care, respectively.

    Medicare recognizes the services furnished under the OPT services benefit as either “always” or “sometimes” therapy and publishes this list as an Annual Update on the Therapy Services Billing page at https://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html.

    On professional claims, each code designated as “always therapy”:

    • Must always be furnished under an SLP, OT, or PT plan of care, regardless of who furnishes them; and, as such,
    • Must always be accompanied by one of the GN, GO, or GP therapy modifiers.

    In addition, several “always therapy” codes have been identified as discipline-specific – requiring the GN modifier for six codes, the GO modifier for four codes, and the GP modifier for four codes, as illustrated in Tables 1-3.

    Table 1: Codes Requiring the “GN” Therapy Modifier

    Code

    Description

    Modifier

    92521

    Evaluation of speech fluency

    GN

    92522

    Evaluate speech production

    GN

    92523

    Speech sound lang comprehend

    GN

    92524

    Behavral quality analys voice

    GN

    92597

    Oral speech device eval

    GN

    92607

    Ex for speech device rx 1hr

    GN

    Table 2: Codes Requiring the “GO” Therapy Modifier

    Code

    Description

    Modifier

    97165

    Ot eval low complex 30 min

    GO

    97166

    Ot eval mod complex 45 min

    GO

    97167

    Ot eval high complex 60 min

    GO

    97168

    Ot re-eval est plan care

    GO

    Table 3: Codes Requiring the “GP” Therapy Modifier

    Code

    Description

    Modifier

    97161

    Pt eval low complex 20 min

    GP

    97162

    Pt eval mod complex 30 min

    GP

    97163

    Pt eval high complex 45 min

    GP

    97164

    Pt re-eval est plan care

    GP

    The following “Always Therapy” HCPCS codes require a GN, GO, or GP modifier, as appropriate. Descriptors for these codes are included as an attachment to CR 10176.

    92507 92508 92526 92608 92609 96125 97012 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97530 97533 97535 97537 97542 97750 97755 97760 97761 97762 97799 G0281 G0283 G0329

    In addition to Therapists in Private Practice (TPPs) – including physical therapists, occupational therapists, and speech-language pathologists – professional claims for OPT services may be furnished by physicians and certain Non-Physician Practitioners (NPPs) – specifically, physician assistants, nurse practitioners, and certified nurse specialists.

    All OPT services furnished by TPPs are always considered therapy services, regardless of whether they are designated as “always therapy” or “sometimes therapy.” As such, the appropriate therapy modifier must be included on the claim. However, it may be clinically appropriate for physicians and NPPs to furnish OPT services that have been designated “sometimes therapy” codes outside a therapy plan of care - in these cases, therapy modifiers are not required and claims may be processed without them.

    During analyses of Medicare claims data for OPT services, the Centers for Medicare & Medicaid Services (CMS) found that these “always therapy” codes and modifiers are not always used in a correct and consistent manner. CMS found OPT professional claims for “always therapy” codes without the required modifiers. Also, CMS found claims that reported more than one therapy modifier for the same therapy service; for example, both a GP and GO modifier, when only one modifier was allowed.

    These claims represent non-compliant billing by TPPs, physicians, and NPPs, and hamper CMS’ ability to properly track the therapy caps and analyze claims data for purposes of Medicare program improvements. The requirements in CR10176 will create new edits for Medicare professional claims processing systems to return claims when “always therapy” codes and the associated therapy modifiers are improperly reported.

    Providers should expect the following:

    • MACs will return/reject claims which contain an “always therapy” procedure code, but do not also contain the appropriate discipline-specific therapy modifier of GN, GO, or GP.
    • MACs will also return/reject claims if any service line on the claim contains more than one occurrence of a GN, GO, or GP therapy modifier.
    • MACs who are returning/rejecting such claims will use Group Code CO and Claim Adjustment Reason Code (CARC) 4 on the related remittance advice.

    Reference

    MLN Matters MM10176

  • Clarification of Payment Policy Changes for Negative Pressure Wound Therapy (NPWT) Using a Disposable Device and the Outlier Payment Methodology for Home Health Services

    24 Feb 2017 11:33 AM | Zachary Edgar (Administrator)

    Effective Date: 3/27/2017

    In the CY 2017 HH PPS Final Rule, CMS finalized clarifications and revisions to policies related to payment for furnishing of NPWT using a disposable device, as well as change to the methodology used to calculate outlier payments to HHAs.

    Negative Pressure Wound Therapy Using a Disposable Device

    The Consolidated Appropriations Act of 2016 (Pub. L. 114-113) requires a separate payment to a HHA for an applicable disposable device when furnished on or after January 1, 2017, to an individual who receives Home Health Services for which payment is made under the Medicare home health benefit. The legislation defines an applicable device as a disposable NPWT device that is an integrated system comprised of a non-manual vacuum pump, a receptacle for collecting exudate, and dressings for the purposes of wound therapy used in lieu of a conventional NPWT DME system. The separate payment amount for a disposable NPWT device is to be set equal to the amount of the payment that would be made under the Medicare Hospital Outpatient Prospective Payment System (OPPS) using the Level I HCPCS code, otherwise referred to as Current Procedural Terminology (CPT® 4) codes, for which the description for a professional service includes the furnishing of such a device.

    Payment for HH visits related to wound care, but not requiring the furnishing of an entirely new disposable NPWT device, will be covered by the HH PPS episode payment and must be billed using the HH claim. Where a HH visit is exclusively for the purpose of furnishing NPWT using a disposable device, the HHA will submit only a type of claim that will be paid for separately outside the HH PPS (Type of Bill (TOB) 34x). Where, however, the home health visit includes the provision of other home health services in addition to, and separate from, furnishing NPWT using a disposable device, the HHA will submit both a home health claim and a TOB 34x—the home health claim covering the other home health services, and the TOB 34x capturing the furnishing of NPWT using a disposable device.

    EXAMPLE: A patient requires NPWT for the treatment of a wound. On Monday, a nurse assesses a patient’s wound, applies a new disposable NPWT device, and provides wound care education to the patient and family. The nurse returns on Thursday for wound assessment and replaces the fluid management system (or dressing) for the existing disposable NPWT, but does not replace the entire device. The nurse returns the following Monday, assesses the patient’s condition and the wound, and replaces the device that had been applied on the previous Monday with a new disposable NPWT device. In this scenario, the billing procedures are as follows:

    For both Monday visits, all the services provided by the nurse were associated with furnishing NPWT using a disposable device. The nurse did not provide any services that were not associated with furnishing NPWT using a disposable device. Therefore, all the nursing services for both Monday visits should be reported on TOB 34x with CPT code 97607 or 97608. None of the services should be reported on the HH claim.

    For the Thursday visit, the nurse checked the wound, but did not apply a new disposable NPWT device. Thus, even though the nurse provided care related to the wound, those services would not be considered furnishing NPWT using a disposable device.

    Therefore, the services should be reported on TOB 32x and no services should be reported on TOB 34x.

    Outlier Payments

    The Centers for Medicare & Medicaid Services (CMS) finalized the proposal to change the methodology used to calculate outlier payments, moving from a cost-per-visit approach to a cost-per-unit approach (1 unit = 15 minutes). This approach more accurately reflects the cost of an outlier episode of care and thus better aligns outlier payments with episode costs than the cost-per-visit approach.

    Reference

    MLN Matters Number: MM9898


  • Updated Editing of Professional Therapy Services

    27 Jan 2017 11:20 AM | Zachary Edgar (Administrator)

    Effective Date: 7/3/2017

    CR9933 implements the following payment policies related to professional claims for therapy services for the new CPT codes for PT and OT evaluative procedures – claims without the required information will be returned/rejected:

    Therapy Modifiers

    The new PT and OT codes are added to the current list of evaluative procedures that require a specific therapy modifier to identify the plan of care under which the services are delivered to be on the claim for therapy services. Therapy modifiers GP, GO, or GN are required to report the type of therapy plan of care – PT, OT, or speech-language pathology, respectively. This payment policy requires that each new PT evaluative procedure code – 97161, 97162, 97163 or 97164 – to be accompanied by the GP modifier; and, (b) each new code for an OT evaluative procedure – 97165, 97166, 97167 or 97168 – be reported with the GO modifier.

    Functional Reporting

    In addition to other Functional Reporting requirements, Medicare payment policy requires Functional Reporting, using G-codes and severity modifiers, when an evaluative procedure is furnished and billed. This notification adds the eight new codes for PT and OT evaluations and re-evaluations – 97161, 97162, 97163, 97164, 97165, 97166, 97167, and 97168 – to the procedure code list of evaluative procedures that necessitate Functional Reporting. A severity modifier (CH – CN) is required to accompany each functional G-code (G8978-G8999, G9158-9176, and G9186) on the same line of service.

    For each evaluative procedure code, Functional Reporting requires either two or three functional G-codes and related severity modifiers be on the same claim. Two G-codes are typically reported on specified claims throughout the therapy episode. However, when an evaluative service is furnished that represents a one-time therapy visit, the therapy clinician reports all three G-codes in the functional limitation set – G-codes for Current Status, Goal Status and Discharge Status.

    CMS coding requirements for Functional Reporting applied through CR9933 ensure that at least two G-codes in a functional set and their corresponding severity modifiers are present on the same claim with any one of the codes on this evaluative procedure code list. The required reporting of G-codes includes: (a) G-codes for Current Status and Goal Status; or, (b) G-codes for Discharge Status and Goal Status.

    For the documentation requirements related to Functional Reporting, please refer to the “Medicare Benefits Policy Manual,” Chapter 15, Section 220.4, which is available at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c15.pdf.

    Claims Coding Requirements

    Therapy Modifiers. Your MAC will return/reject professional claims when:

    • Reporting codes 97161, 97162, 97163, or 97164 without the GP modifier.
    • Reporting codes 97165, 97166, 97167, or 97168 without the GO modifier.
    • Reporting an “always therapy” code without a therapy modifier

    For these returned/rejected claims, your MAC will supply the following messages:

    • Group code CO
    • CARC – 4: The procedure code is inconsistent with the modifier used or a required modifier is missing.

    Functional Reporting. Your MAC will return/reject claims when:

    • The professional claims you submit for the new therapy evaluative procedures, codes 97161- 97168, without including one of the following pairs of G-codes/severity modifiers required for Functional Reporting: (a) A Current Status G-code/severity modifier paired with a Goal Status G-code/severity modifier; or, (b) A Goal Status G-code/severity modifier paired with a Discharge Status G-code/severity modifier.

    Your MAC will provide the following remittance messages when returning such submissions:

    • Group code of CO (contractual obligation)
    • Claim Adjustment Reason Code (CARC) – 16: Claim/service lacks information or has submission/billing error(s) which is needed for adjudication.
    • Remittance Advice Remarks Code (RARC) – N572: This procedure is not payable unless non-payable reporting codes and appropriate modifiers are submitted.

    Reference

    MLN Matters Number: MM9933

  • Update to Editing of Therapy Services to Reflect Coding Changes

    1 Dec 2016 1:43 PM | Zachary Edgar (Administrator)

    December 1, 2016

    This change request instructs contractors to add new Common Procedure Terminology (CPT) codes to report physical and occupational therapy evaluations.

    A. Background: Original Medicare claims processing systems contain edits to ensure claims for the evaluative procedures furnished by rehabilitative therapy clinicians – including physical therapists, occupational therapists and speech-language pathologists – are coded correctly. These edits ensure that when the codes for evaluative services are submitted, the therapy modifier (GP, GO or GN) that reports the type of therapy plan of care is consistent with the discipline described by the evaluation or re-evaluation code. The edits also ensure that Functional Reporting occurs, i.e., that functional G-codes, along with severity modifiers, always accompany codes for therapy evaluative services.

    For calendar year (CY) 2017, eight new CPT codes (97161-97168) were created to replace existing codes (97001-97004) to report physical therapy (PT) and occupational therapy (OT) evaluations and reevaluations. The new CPT code descriptors include specific components that are required for reporting as well as the typical face-to-face times. In another recent issuance, Change Request (CR) 9782, we described the new PT and OT code sets, each comprised of three new codes for evaluation – stratified by low, moderate, and high complexity – and one code for re-evaluation. CR 9782 designated all eight new codes as “always therapy” (always require a therapy modifier) and added them to the 2017 therapy code list located on the Centers for Medicare & Medicaid Services (CMS) website at http://www.cms.gov/Medicare/Billing/TherapyServices/index.html. For a complete listing of the new codes, their CPT long descriptors, and related policies, please refer to CR 9782.

    This notification applies the coding requirements for certain evaluative procedures that are currently outlined in Pub. 100-04, Medicare Claims Processing Manual (MCPM), Chapter 5 to the new codes for PT and OT evaluations and re-evaluations. These coding requirements include the payment policies for evaluative procedures that (a) require the application of discipline-specific therapy modifiers and (b) necessitate Functional Reporting using G-codes and severity modifiers. The new codes are also added to the list of evaluation codes that CMS will except from the caps after the therapy caps are reached when an evaluation is necessary, e.g., to determine if the current status of the beneficiary requires therapy services.

    In addition, this Change Request (CR) updates and clarifies information in MCPM, Pub. 100-04, Chapter 5.

    B. Policy: This notification implements the following payment policies related to claims for therapy services for the new codes for PT and OT evaluative procedures – claims without the required information will be returned as unprocessable:

    Therapy modifiers. The new PT and OT codes are added to the current list of evaluative procedures that require a specific therapy modifier to identify the plan of care under which the services are delivered to be on the claim for therapy services. Therapy modifiers GP, GO or GN are required to report the type of therapy plan of care – PT, OT, or speech language pathology (SLP), respectively. This payment policy requires that each new PT evaluative procedure code – 97161, 97162, 97163 or 97164 – to be accompanied by the GP modifier; and, (b) each new code for an OT evaluative procedure – 97165, 97166, 97167 or 97168 – be reported with the GO modifier.

    Functional Reporting (FR). In addition to other Functional Reporting requirements, current payment policy requires Functional Reporting, using G-codes and severity modifiers, when an evaluative procedure is furnished and billed. This notification adds the eight new codes for PT and OT evaluations and reevaluations – 97161, 97162, 97163, 97164, 97165, 97166, 97167, and 97168 – to the procedure code list of evaluative procedures that necessitate Functional Reporting. A severity modifier (CH – CN) is required to accompany each functional G-code (G8978-G8999, G9158-9176, and G9186) on the same line of service.

    For each evaluative procedure code, Functional Reporting requires either two or three functional G-codes and related severity modifiers be on the same claim. Two G-codes are typically reported on specified claims throughout the therapy episode. However, when an evaluative service is furnished that represents a one-time therapy visit, the therapy clinician reports all three G-codes in the functional limitation set – G-codes for Current Status, Goal Status and Discharge Status. For the documentation requirements related to Functional Reporting, please refer to Pub. 100-02, Medicare Benefits Policy Manual, chapter 15, section 220.4.

    CMS coding requirements for Functional Reporting applied through this notification ensure that at least two G-codes in a functional set and their corresponding severity modifiers are present on the same claim with any one of the codes on this evaluative procedure code list. The required reporting of G-codes includes: (a) G-codes for Current Status and Goal Status; or, (b) G-codes for Discharge Status and Goal Status.

    Reference

    Medicare Transmittal # R3670CP

    December 1, 2016


  • 2017 Annual Update to the Therapy Code List

    10 Nov 2016 1:45 PM | Zachary Edgar (Administrator)

    November 10, 2016

    SUMMARY OF CHANGES: This Change Request 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 CY 2017 Healthcare Common Procedure Coding System and Current Procedural Terminology, Fourth Edition (HCPCS/CPT-4). The attached Recurring Update Notification applies to Chapter 5, Section 10.6

    A. Background: Section 1834(k)(5) of the Act requires that all claims for outpatient rehabilitation therapy services and all comprehensive outpatient rehabilitation facility services be reported using a uniform coding system. The CY 2017 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.

    This change request (CR) 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 CY 2017 HCPCS/CPT-4. The therapy code listing can be found on the Centers for Medicare & Medicaid Services (CMS) Web site at http://www.cms.gov/Medicare/Billing/TherapyServices/index.html.

    B. Policy:The policies implemented in this notification were discussed in CY 2017 Medicare Physician Fee Schedule (MPFS) rulemaking. This CR updates the therapy code list and associated policies for CY 2017, as follows:

    For CY 2017, the Current Procedural Terminology (CPT) Editorial Panel created eight new codes (97161- 97168) to replace the 4-code set (97001-97004) for physical therapy (PT) and occupational therapy (OT) evaluative procedures. The new CPT code descriptors for PT and OT evaluative procedures include specific components that are required for reporting as well as the corresponding typical face-to-face times for each service. Refer to Tables 1 and 2 in the Attachment for a complete listing of the new CPT codes for PT and OT evaluative procedures and their long descriptors.

    PT and OT evaluation codes. The CPT Editorial Panel created three new codes to replace each existing PT and OT evaluation code, 97001 and 97003, respectively. These new evaluation codes are based on patient complexity and the level of clinical decision-making – low, moderate and high complexity: for PT, codes 97161, 97162 and 97163; and for OT, codes 97165, 97166 and 97167.

    PT and OT re-evaluation codes. One new PT code, 97164, and one new OT code, 97168, were created to replace the existing codes – 97002 and 97004, respectively. The re-evaluation codes are reported for an established patient’s when a revised plan of care is indicated.

    Just as their predecessor codes were, the new codes are “always therapy” and must be reported with the appropriate therapy modifier, GP or GO, to indicate that the services are furnished under a PT or OT plan of care, respectively.

    The therapy code list is updated with eight new “always therapy” codes, using their CPT short descriptors, as follows:

    The new codes for PT Evaluative procedures (97161-97164):

    • The three new PT evaluation codes 97161, 97162, and 97163 replace code 97001
    • Add: 97161 - PT EVAL LOW COMPLEX 20 MIN
    • Add: 97162 - PT EVAL MOD COMPLEX 30 MIN
    • Add: 97163 - PT EVAL HIGH COMPLEX 45 MIN
    • Delete: 97001 - PT EVALUATION
    • The new PT re-evaluation code 97164 replaces code 97002
    • Add: 97164 - PT RE-EVAL EST PLAN CARE
    • Delete: 97002 - PT RE-EVALUATION

    The new codes for OT Evaluative procedures (97165-97168):

    • The three new OT evaluation codes 97165, 97166, and 97167 replace code 97003
    • Add: 97165 - OT EVAL LOW COMPLEX 30 MIN
    • Add: 97166 - OT EVAL MOD COMPLEX 45 MIN
    • Add: 97167 - OT EVAL HIGH COMPLEX 60 MIN
    • Delete: 97003 – OT EVALUATION
    •  The new OT re-evaluation code 97168 replaces 97004
    • Add: 97168 - OT RE-EVAL EST PLAN CARE
    • Delete: 97004 – OT RE-EVALUATION

    For CY 2017 - New CPT Codes and Long Descriptors for PT Evaluative Procedures

    97161 - Physical therapy evaluation: low complexity, requiring these components:

    • A history with no personal factors and/or comorbidities that impact the plan of care;
    • An examination of body system(s) using standardized tests and measures addressing 1-2 elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
    • A clinical presentation with stable and/or uncomplicated characteristics; and
    • Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.

    Typically, 20 minutes are spent face-to-face with the patient and/or family.

    97162 - Physical therapy evaluation: moderate complexity, requiring these components:

    • A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care;
    • An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
    • An evolving clinical presentation with changing characteristics; and
    • Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.

    Typically, 30 minutes are spent face-to-face with the patient and/or family.

    97163 - Physical therapy evaluation: high complexity, requiring these components:

    • A history of present problem with 3 or more personal factors and/or comorbidities that impact the plan of care;
    • An examination of body systems using standardized tests and measures addressing a total of 4 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions;
    • A clinical presentation with unstable and unpredictable characteristics; and
    • Clinical decision making of high complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.

    Typically, 45 minutes are spent face-to-face with the patient and/or family.

    97164 - Re-evaluation of physical therapy established plan of care, requiring these components:

    • An examination including a review of history and use of standardized tests and measures is required; and
    • Revised plan of care using a standardized patient assessment instrument and/or measurable assessment of functional outcome.

    Typically, 20 minutes are spent face-to-face with the patient and/or family.

    For CY 2017: New CPT Codes and Long Descriptors for OT Evaluative Procedures

    97165 - Occupational therapy evaluation, low complexity, requiring these components:

    • An occupational profile and medical and therapy history, which includes a brief history including review of medical and/or therapy records relating to the presenting problem;
    • An assessment(s) that identifies 1-3 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
    • Clinical decision making of low complexity, which includes an analysis of the occupational profile, analysis of data from problem-focused assessment(s), and consideration of a limited number of treatment options. Patient presents with no comorbidities that affect occupational performance. Modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is not necessary to enable completion of evaluation component.

    Typically, 30 minutes are spent face-to-face with the patient and/or family.

    97166 - Occupational therapy evaluation, moderate complexity, requiring these components:

    • An occupational profile and medical and therapy history, which includes an expanded review of medical and/or therapy records and additional review of physical, cognitive, or psychosocial history related to current functional performance;
    • An assessment(s) that identifies 3-5 performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
    • Clinical decision making of moderate analytic complexity, which includes an analysis of the occupational profile, analysis of data from detailed assessment(s), and consideration of several treatment options. Patient may present with comorbidities that affect occupational performance. Minimal to moderate modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.

    Typically, 45 minutes are spent face-to-face with the patient and/or family.

    97167 - Occupational therapy evaluation, high complexity, requiring these components:

    • An occupational profile and medical and therapy history, which includes review of medical and/or therapy records and extensive additional review of physical, cognitive, or psychosocial history related to current functional performance;
    • An assessment(s) that identifies 5 or more performance deficits (i.e., relating to physical, cognitive, or psychosocial skills) that result in activity limitations and/or participation restrictions; and
    • Clinical decision making of high analytic complexity, which includes an analysis of the patient profile, analysis of data from comprehensive assessment(s), and consideration of multiple treatment options. Patient presents with comorbidities that affect occupational performance. Significant modification of tasks or assistance (e.g., physical or verbal) with assessment(s) is necessary to enable patient to complete evaluation component.

    Typically, 60 minutes are spent face-to-face with the patient and/or family.

    97168 - Re-evaluation of occupational therapy established plan of care, requiring these components:

    • An assessment of changes in patient functional or medical status with revised plan of care;
    • An update to the initial occupational profile to reflect changes in condition or environment that affect future interventions and/or goals; and
    • A revised plan of care. A formal reevaluation is performed when there is a documented change in functional status or a significant change to the plan of care is required.

    Typically, 30 minutes are spent face-to-face with the patient and/or family.

    Reference

    Medicare Transmittal # R3654CP

    November 10, 2016

  • Therapy Cap Values for Calendar Year (CY) 2017

    4 Nov 2016 1:55 PM | Zachary Edgar (Administrator)

    November 4, 2016

    Effective Date: January 1, 2017

    Background: The Balanced Budget Act of 1997, P.L. 105-33, Section 4541(c) applies, per beneficiary, annual financial limitations on expenses considered incurred for outpatient therapy services under Medicare Part B, commonly referred to as “therapy caps.” The therapy caps are updated each year based on the Medicare Economic Index. An exceptions process to the therapy caps for reasonable and medically necessary services was required by section 5107 of the Deficit Reduction Act of 2005. The exceptions process for the therapy caps has been continuously extended several times through subsequent legislation. Most recently, section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended the therapy caps exceptions process through December 31, 2017.

    Policy: Contractors shall update the allowed dollar amount for CY 2017 outpatient therapy limits to $1,980 for physical therapy and speech-language pathology combined and $1,980 for occupational therapy

    Reference

    Medicare Transmittal # R3644CP

    November 4, 2016


  • Correction to Applying Therapy Caps to Maryland Hospitals and Billing Requirement for Rehabilitation Agencies and Comprehensive Outpatient Rehabilitation Facilities (CORFs)

    4 Feb 2016 1:56 PM | Zachary Edgar (Administrator)

    February 4, 2016

    This Change Request (CR) modifies the requirements of CR 9223 to ensure therapy caps are applied correctly to claims from certain Maryland hospitals.

    Background:Change Request (CR) 9223 applied the therapy caps and related policies to Maryland outpatient hospital claims (Types of Bill 012x and 013x submitted with CMS Certification Numbers (CCNs) beginning with 21). The CR applied cap amounts based on the submitted charge amount on covered outpatient therapy service lines, before applying coinsurance or deductible. This is the correct application of the cap amounts for the majority of Maryland hospitals.

    However, certain specialty hospitals in Maryland are not paid under the Maryland All-Payer Model. These hospitals are paid for therapy services using the Medicare Physician Fee Schedule (MPFS) amounts. The therapy cap amounts for these claims should be the MPFS amount, before applying coinsurance or deductible, not the submitted charge. Since these hospitals also have CCNs beginning with 21, the implementation of CR 9223 caused Medicare systems to begin using the submitted charge amount instead.

    As a result of this error, the therapy cap and threshold totals for beneficiaries served by these specialty hospitals is incorrect. In many cases the totals may be overstated. The requirements below correct the error in Medicare systems and instruct the Medicare Administrative Contractors to adjust claims to correct the therapy cap totals for affected beneficiaries.

    Additionally, this CR adds instructions to the Medicare Claims Processing Manual to add a new billing requirement for rehabilitation agencies and CORFs when these providers operate multiple sites in differing payment localities as determined by the MPFS. These MPFS payment localities are determined by the 9- digit ZIP code where services are provided. .

    Policy:For MD hospitals, this CR contains no new policy. It corrects the implementation of the policy established in CR 9223.

    This CR adds a new billing requirement policy for rehabilitation agencies and CORFs. When rehabilitation agencies and CORFs furnish a service in an off-site location that is in a different 9-digit ZIP code from that of the primary or parent location, the off-site location ZIP code must be reported on the claim. Since these providers are paid subject to the MPFS, the new billing requirement ensures that payments are adjusted based on the applicable payment locality. Until now, rehabilitation agencies and CORFs did not have a mechanism to accurately report the 9-digit ZIP code for the services they provide in off-site locations with differing payment localities. Where a rehabilitation agency or CORF has only one service location, the ZIP code of the primary site of record is used as the MPFS payment locality.

    Reference

    Medicare Transmittal # R3454CP

    February 4, 2016


  • Therapy Cap Values for Calendar Year (CY) 2016

    25 Nov 2015 12:30 PM | Zachary Edgar (Administrator)

    November 25, 2015

    Background: The Balanced Budget Act of 1997, P.L. 105-33, Section 4541(c) applies, per beneficiary, annual financial limitations on expenses considered incurred for outpatient therapy services under Medicare Part B, commonly referred to as “ therapy caps”. The therapy caps are updated each year based on the Medicare Economic Index. An exceptions process to the therapy caps for reasonable and medically necessary services was required by section 5107 of the Deficit Reduction Act of 2005. The exceptions process for the therapy caps has been continuously extended several times through subsequent legislation. Most recently, section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 extended the therapy caps exceptions process through December 31, 2017.

    Policy: Therapy caps for CY 2016 will be $1,960.

    Contractors shall update the allowed dollar amount for CY 2016 outpatient therapy limits to $1,960 for physical therapy and speech-language pathology combined and $1,960 for occupational therapy.

    Reference

    Medicare Transmittal # R3417CP

    November 25, 2015


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