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Therapy Blog Spot

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  • 14 Jul 2021 10:31 AM | Zachary Edgar (Administrator)

    CMS is proposing to revise the de minimis standard established to determine whether services are provided “in whole or in part” by PTAs or OTAs. Specifically, CMS is proposing to revise the de minimis policy to allow a timed service to be billed without the CQ/CO modifier in cases when a PTA/OTA participates in providing care to a patient with a physical therapist or occupational therapist (PT/OT), but the PT/OT meets the Medicare billing requirements for the timed service without the minutes furnished by the PTA/OTA by providing more than the 15-minute midpoint (also known as the 8-minute rule).

    Under this proposal, any minutes that the PTA/OTA furnishes in the scenarios described above would not matter for purposes of billing Medicare. In addition to cases where one remaining unit of a multi-unit therapy service to be billed, this revision to the policy would apply in a limited number of cases where more than one unit of therapy, with a total time of 24-28 minutes is being furnished. For these limited cases, CMS is proposing to allow one 15-minute unit to be billed with the CQ/CO assistant modifier and one 15-minute unit to be billed without the CQ/CO modifier in billing scenarios where there are two 15-minute units left to bill when the PT/OT and the PTA/OTA each provide between 9 and 14 minutes of the same service. 

    Overall, the de minimis standard would continue to be applicable in the following scenarios:

    • When the PTA/OTA independently furnishes a service, or a 15-minute unit of a service “in whole” without the PT/OT furnishing any part of the same service. 
    • In instances where the service is not defined in 15-minute increments including:  supervised modalities, evaluations/reevaluations, and group therapy.
    • When the PTA/OTA furnishes eight minutes or more of the final unit of a billing scenario in which the PT/OT furnishes less than eight minutes of the same service. 
    • When both the PTA/OTA and the PT/OT each furnish less than eight minutes for the final 15-minute unit of a billing scenario. 

    Example #A:

    PTA - 10 minutes of 97110

    PT – 5 minutes of 97110

    Total = 15 minutes – qualifies to bill one 15-minute unit (8 minute to 22 minutes).

    Analysis: Bill one unit of 97110 with the CQ modifier because the PTA provided 8 minutes or more and the PT provided less than 8 minutes. The de minimis standard applies in these cases.

    Example #B:

    PTA - 5 minutes of 97110

    PT - 6 minutes of 97110

    Total = 11 minutes – qualifies to bill one 15-minute unit (8 minute through 22 minutes).

    Analysis: Bill one unit of 97110 with the CQ modifier because the PTA and the PT both provided less than 8 minutes. In this case, the PT provided 6 minutes and the PTA furnished 5 minutes independent of each other. The de minimis standard applies in these cases.

    Example #C:

    PTA-22 minutes of 97110

    PT – 23 minutes of 97110

    Total = 45 minutes ─ qualifies to bill three 15-minute units (38 minutes through 52 minutes).

    Analysis:

    Apply Step One of the general policy rules and bill one unit of 97110 with the CQ modifier because the PTA provided 15 full minutes with 7 minutes remaining.

    Apply Step One to the PT’s 23 minutes and bill one unit without the assistant modifier with 8 minutes remaining.

    The third unit of 97110 is billed without the assistant modifier because the therapist provided enough minutes (8 or more minutes) without the PTAs minutes to bill the final unit.

    Example #D

    PT – 12 minutes of 97110

    PTA-14 minutes of 97110

    PT – 20 minutes of 97140

    Total = 46 minutes – qualifies to bill three units (38 minutes through 52 minutes)

    Analysis:

    Apply Step One of the general policy rules and bill one unit of 97140 without the CQ modifier because the PT provided 15 full minutes of one unit with 5 minutes remaining.

    Two units remain to be billed and the PT and the PTA each provided between 9 and 14 minutes independent of one another with a total time between 23 and 28 minutes – in these “two remaining unit” scenarios, one unit is billed with the CQ modifier for the PTA and the other unit is billed without it for the PT.

    The PT’s 5 remaining minutes of 97140 are counted towards the total timed minutes but are not billable in this scenario.

    Example #E

    OTA-11 minutes of 97535

    OT – 11 minutes of 97530

    Total = 22 minutes ─ qualifies to bill one (1) unit (8 minutes through 22 minutes)

    Billing Analysis:

    Since two different services were furnished for an equal number of minutes – the “tie breaker” scenario applies. Either code 97530 by the OT or code 97535 by the OTA can be billed in accordance with a billing example.  Either one unit of 97530 is billed without the CO modifier or one unit of 97535 is billed with the CO modifier.

    Example #F: Untimed code – 1 unit is billed for all untimed codes including evaluations, reevaluations, supervised modalities, and group therapy.

    OTA – 20 minutes 97150 independent of the OT

    OT ─ 20 minutes 97150 independent of the OTA

    Total = 40 minutes of Group Therapy = 1 unit of 97150 is billed for each group member

    Billing Analysis:

    One unit of group therapy 97150 is billed with the CO modifier because the OTA provided more than the 10 percent time standard in this example. Either method can be used to determine if the OTA’s time exceeded the 10 percent time standard for this clinical scenario, see below:

    The simple method: First add the OTA’s 20 minutes to the OT’s 20 minutes to get 40, then divide by 10 to get 4.0 and add 1 to equal 5 minutes. The OTA’s 20 minutes is equal to or greater than 5 minutes so the CO modifier is required on the claim.

    The percentage method: Divide the number of minutes that an OTA independently furnished a service by the total number of minutes the service was furnished as a whole – 20 divided by 40 equals 0.50. Then multiple by 100 to get 50 percent, which is greater than 10 percent. The CO modifier is applied to 97150.

    Tie breaker: The tie breaker does not apply in this scenario because the example does not contain two different timed codes described in 15-minute intervals. For “tie breaker” see Example #F above.

    Reference

    Fed. R. 2021 -14973


  • 3 Jun 2021 1:31 PM | Zachary Edgar (Administrator)

    NCCI PTP for Outpatient Hospital Practitioners 

    Now you can use modifier 59 to bypass edits for Eval codes and 96156-96156.

    97161 96156 1
    97161 96159 1
    97161 96164 1
    97161 96165 1
    97162 96156 1
    97162 96158 1
    97162 96159 1
    97162 96164 1
    97162 96165 1
    97163 96156 1
    97163 96158 1
    97163 96159 1
    97163 96164 1
    97163 96165 1
    97164 96156 1
    97164 96158 1
    97164 96159 1
    97164 96164 1
    97164 96165 1
    97165 96156 1
    97165 96158 1
    97165 96159 1
    97165 96164 1
    97165 96165 1
    97166 96156 1
    97166 96158 1
    97166 96159 1
    97166 96164 1
    97166 96165 1
    97167 96156 1
    97167 96158 1
    97167 96159 1
    97167 96164 1
    97167 96165 1
    97168 96156 1
    97168 96158 1
    97168 96159 1
    97168 96164 1


  • 23 Feb 2021 2:55 PM | Zachary Edgar (Administrator)

    Visit our NCCI page for all therapy edits.

    CMS published new edit files effective Jan. 1, 2021, and made the edit deletions retroactively effective to Jan. 1, 2020. Humana’s policy is consistent with the CMS changes.

    The Humana decision significantly reduces the instances in which a PT will need to append the 59, X, XE, XP, XS, or XU modifiers and will eliminate situations in which certain code pairs were prohibited. The change is anticipated to have a positive impact on the provision of necessary care and reduce administrative burden associated with claim denials and appeals.

    According to Humana, it will reprocess claims that were denied based on the edits dating back to Jan. 1, 2020, if a provider resubmits the claim.

    Each insurer is approaching the shift in different ways when it comes to how claims will be processed:

    • CIGNA will not retroactively process claims but will acknowledge the NCCI edits deletions starting Jan. 1, 2021.
    • Aetna will retroactively reprocess claims to Jan 1, 2020. Providers do not need to resubmit their claims; instead, Aetna will auto-process the claims. The insurer says this could take several months.
    • Humana will retroactively reprocess claims to Jan. 2, 2020; however, unlike Aetna, providers must resubmit claims.


  • 23 Dec 2020 10:04 AM | Zachary Edgar (Administrator)

    House bill 133 addressed steep Medicare payment cuts to physical, speech-language, and occupational therapy by providing a 3.75% increase to all payments made under the Medicare Physician Fee Schedule in 2021.  This means that payment rates will be reduced by 5.25% instead of 9%.  Although this fix is only for 2021 and does not completely eliminate the cuts, other provisions of the legislation may soften the impact of the cuts further. Early estimates show that H.R. 133 could decrease the 2021 cuts by a total of about 2/3 the original impact calculated by CMS.


  • 11 Dec 2020 4:16 PM | Zachary Edgar (Administrator)

    Department of Health and Human Services has issued a proposed rule that will make significant changes to the HIPAA Privacy Rule.

    Here is the summary of the changes:

    • Strengthening individuals’ rights to inspect their PHI in person, which includes allowing individuals to take notes or use other personal resources to view and capture images of their PHI.
    • Shortening covered entities’ required response time to no later than 15 calendar days (from the current 30 days) with the opportunity for an extension of no more than 15 calendar days (from the current 30-day extension).
    • Clarifying the form and format required for responding to individuals’ requests for their PHI.
    • Requiring covered entities to inform individuals that they retain their right to obtain or direct copies of PHI to a third party when a summary of PHI is offered in lieu of a copy.
    • Reducing the identity verification burden on individuals exercising their access rights.
    • Creating a pathway for individuals to direct the sharing of PHI in an EHR among covered health care providers and health plans, by requiring covered health care providers and health plans to submit an individual’s access request to another health care provider and to receive back the requested electronic copies of the individual’s PHI in an HER.
    • Requiring covered health care providers and health plans to respond to certain records requests received from other covered health care providers and health plans when directed by individuals pursuant to the right of access.
    • Limiting the individual right of access to direct the transmission of PHI to a third party to electronic copies of PHI in an HER.
    • Specifying when electronic PHI (ePHI) must be provided to the individual at no charge.
    • Amending the permissible fee structure for responding to requests to direct records to a third party.
    • Requiring covered entities to post estimated fee schedules on their websites for access and for disclosures with an individual’s valid authorization and, upon request, provide individualized estimates of fees for an individual’s request for copies of PHI, and itemized bills for completed requests.
    • Amending the definition of health care operations to clarify the scope of permitted uses and disclosures for individual-level care coordination and case management that constitute health care operations.
    • Creating an exception to the “minimum necessary” standard for individual-level care coordination and case management uses and disclosures. The minimum necessary standard generally requires covered entities to limit uses and disclosures of PHI to the minimum necessary needed to accomplish the purpose of each use or disclosure. This proposal would relieve covered entities of the minimum necessary requirement for uses by, disclosures to, or requests by, a health plan or covered health care provider for care coordination and case management activities with respect to an individual, regardless of whether such activities constitute treatment or health care operations.
    • Clarifying the scope of covered entities’ abilities to disclose PHI to social services agencies, community-based organizations, home and community based service (HCBS) providers, and other similar third parties that provide health-related services, to facilitate coordination of care and case management for individuals.
    • Replacing the privacy standard that permits covered entities to make certain uses and disclosures of PHI based on their “professional judgment” with a standard permitting such uses or disclosures based on a covered entity’s good faith belief that the use or disclosure is in the best interests of the individual. The proposed standard is more permissive in that it would presume a covered entity’s good faith, but this presumption could be overcome with evidence of bad faith.
    • Expanding the ability of covered entities to disclose PHI to avert a threat to health or safety when a harm is “serious and reasonably foreseeable,” instead of the current stricter standard which requires a “serious and imminent” threat to health or safety.
    • Eliminating the requirement to obtain an individual’s written acknowledgment of receipt of a direct treatment provider’s Notice of Privacy Practices (NPP).
    • Modifying the content requirements of the NPP to clarify for individuals their rights with respect to their PHI and how to exercise those rights.
    • Expressly permitting disclosures to Telecommunications Relay Services (TRS) communications assistants for persons who are deaf, hard of hearing, or deafblind, or who have a speech disability, and modifying the definition of business associate to exclude TRS providers.
    • Expanding the Armed Forces permission to use or disclose PHI to all uniformed services, which then would include the U.S. Public Health Service (USPHS) Commissioned Corps and the National Oceanic and Atmospheric Administration (NOAA) Commissioned Corps.

    Reference

    Proposed Modifications to the HIPAA Privacy Rule to Support, and Remove Barriers to, Coordinated Care and Individual Engagement available at https://www.hhs.gov/sites/default/files/hhs-ocr-hipaa-nprm.pdf


  • 9 Dec 2020 4:20 PM | Zachary Edgar (Administrator)

    For CY 2021, the KX modifier threshold amounts are:

    • $2,110 for Physical Therapy (PT) and Speech-Language Pathology (SLP) services combined, and
    • $2,110 for Occupational Therapy (OT) services.


    Medicare now refers to this threshold amount as the Medical Record (MR) threshold amount – one MR threshold amount for PT and SLP services combined and another for OT services. This amount remains at $3,000 until CY 2028 at which time Medicare will update it based on the MEI.

  • 2 Dec 2020 11:57 AM | Zachary Edgar (Administrator)

    The 2021 Medicare Physician Fee Schedule was released today.  Join us  for a CE webinar on key changes to Medicare therapy services next year:

    December 9 at 12:00 PM CST

    December 10 at 12:00 PM EST

    December 16 at 12:00 PM CST

    December 17 at 12:00 PM EST

    Key Changes:

    • 9% rate cuts for Part B physical and occupational therapy services.  
    • Increased payment for evaluations.
    • Telehealth expansion:  Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161-97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507)
    • PTs, OTs, and SLPs can furnish the brief online assessment and management services as well as virtual check-ins and remote evaluation services. In order to facilitate billing by these practitioners for the remote evaluation of patient-submitted video or images and virtual check-ins (HCPCS codes G2010 and G2012)
    • Physical therapists  and occupational therapists can now delegate the furnishing of maintenance therapy services, as clinically appropriate, to a physical therapy assistant (PTA) or an occupational therapy assistant (OTA). 
    • Physicians and NPPs, including therapists, can review and verify documentation entered into the medical record by members of the medical team for their own services that are paid under the PFS. 

    • CMS clarifies that therapy students, and students of other disciplines, working under a physician or practitioner who furnishes and bills directly for their professional services to the Medicare program, may document in the record so long as the documentation is reviewed and verified (signed and dated) by the billing physician, practitioner, or therapist.

  • 17 Mar 2020 1:41 PM | Zachary Edgar (Administrator)

    Medicare is now allowing physical, occupational, and speech therapists to bill for E-visits with patients.

    E-VISITS:  In all types of locations including the patient’s home, and in all areas (not just rural), established Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals. These services can only be reported when the billing practice has an established relationship with the patient. For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would apply to these services.

    Medicare Part B also pays for E-visits or patient-initiated online evaluation and management conducted via a patient portal. Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes:

    • 99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes
    • 99422: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes
    • 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.

    Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can also provide these e-visits and bill the following codes:

    • G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes
    •  G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes
    • G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.

    KEY TAKEAWAYS:

    • These services can only be reported when the billing practice has an established relationship with the patient. 
    • This is not limited to only rural settings. There are no geographic or location restrictions for these visits.
    • Patients communicate with their doctors without going to the doctor’s office by using online patient portals.
    • Individual services need to be initiated by the patient; however, practitioners may educate beneficiaries on the availability of the service prior to patient initiation. 
    • The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable.
    • The Medicare coinsurance and deductible would generally apply to these services.

    HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA):  Effective immediately, the HHS Office for Civil Rights (OCR) will exercise enforcement discretion and waive penalties for HIPAA violations against health care providers that serve patients in good faith through everyday communications technologies, such as FaceTime or Skype, during the COVID-19 nationwide public health emergency.  For more information: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/index.html


    Reference

    Medicare Telemedicine Health Care Provider Fact SheetMar 17, 2020, available at https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet


  • 13 Mar 2020 11:07 AM | Zachary Edgar (Administrator)

    Upcoming Webinar: Telehealth for Physical and Occupational Therapy

    March 25, 2020 at 12:00 PM - 1:00 PM CDT

    April 1, 2020 at 12:00 PM - 1:00 PM EDT

    Telehealth and Other Communication-Based Technology Services

    Beneficiaries can communicate with their doctors or certain other practitioners without necessarily going to the doctor’s office in person for a full visit.

    Since 2018, Medicare pays for “virtual check-ins” for patients to connect with their doctors without going to the doctor’s office. These brief, virtual check-in services are for patients with an established relationship with a physician or certain practitioners where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to using virtual check-ins and the consent must be documented in the medical record prior to the patient using the service. The Medicare coinsurance and deductible would apply to these services.

    Doctors and certain practitioners may bill for these virtual check-in services furnished through several communication technology modalities, such as telephone (HCPCS code G2012) or captured video or image (HCPCS code G2010).

    Medicare also pays for patients to communicate with their doctors without going to the doctor’s office using online patient portals. The individual communications, like the virtual check ins, must be initiated by the patient; however, practitioners may educate beneficiaries on the availability of this kind of service prior to patient initiation. The communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G206, as applicable. The Medicare coinsurance and deductible would apply to these services.

    In addition, Medicare beneficiaries living in rural areas may use communication technology to have full visits with their physicians. The law requires that these visits take place at specified sites of service, known as telehealth originating sites, and receive services using a real-time audio and video communication system at the site to communicate with a remotely located doctor or certain other types of practitioners. Medicare pays for many medical visits through this telehealth benefit. Certain beneficiaries, such as those needing a monthly end-stage renal disease visit or those needing treatment for substance use disorders or co-occurring mental health disorder may access telehealth services from their home without traveling to an originating site.

    The Medicare coinsurance and deductible would apply to these services.

    Medicare also pays doctors for certain non-face-to-face care management services and remote patient monitoring services. The Medicare coinsurance and deductible would apply to these services.

    References

    CMS Fact Sheet Coverage and Payment Related to COVID-19 Medicare Posted March 3, 2020


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