Problematic CPT Code Billing Edits Effective 1/1/2020

For our long-term care residents (Medicare Part B), billing for PT, OT and ST services is submitted utilizing CPT codes delivered. On January 1st, 2020, CMS announced through their National Correct Coding Initiative contractor (NCCI), that effective 1/1/2020 it will no longer be allowing two frequently used treatment codes to be billed on the same day as the evaluation codes for PT and OT. Another twist for example: if an OT eval is completed - neither OT or PT would be able to bill for therapeutic activities or group on that same day. There is a great amount of action being taken by APTA, AOTA, NASL and NARA to clearly point out the potential consequences of this restriction being applied across disciplines as well as limiting the services which can be delivered to a patient on their initial evaluation day. This does not seem to coincide with current value driven outcome-based initiatives. While there is slight hope that CMS may reverse action, rehab software platforms, Casamba and Optima, jumped into action and have built in edits to provide safety nets for therapists as they plan, deliver and bill for care provided.

The CPT treatment codes that cannot be utilized on the same day as the evaluation codes - across disciplines are as noted below:

  • CPT Treatment Codes: 97530 (therapeutic activities) and 97150 (therapeutic procedures, group, 2 or more individuals)

  • CPT Evaluation Codes: 97161–97163 (PT Eval) and 97165–97167 (OT Eval)

Let's Get to the Point:

We will continue to monitor this edit issue and provide updates as we learn more. We hope to eliminate any surprises at month end during the billing process. Please feel free to share this update with those in your billing and rehab departments and let us know of any questions or additional help we can provide as we navigate through these New Year updates.