Payment

Current Payment News

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  • COVID Resources
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May 24, 2021

To Mask or Not to Mask?? 
Click here all your masking answers and more regarding RI’s adoption of latest CDC COVID recommendations.
 
Payment Updates:
Tufts Updated Policy 
  • Tufts adopted NCCI Edits 
  • When modifier 59 is applied, code reimbursement is reduced by 50%.
Click Here for updated Policy : Look under embedded link in the 59 description details.
 
NHP of RI
  • Updated Policy as if 4/19 for OP PT: 
  • RI APTA working for you: Decreased admin burden and removal of capped visits at 24
  • Payment Committee continues to work with NHP to gain further clarification of documentation requirements. 
  • Click here for Policy Update  Visit NHP website for full Policy
 
BCBS Rhode Island
  • Posts updated Early Intervention Services Mandate 5-2021
--Added "Commercial Products" to Policy Statement and Coding sections
--Revised coding table
--Updated Related Policies
  • Please see Policy and Version Compare feature on your Landscape for more details.
 

 

2/17/21

Payor Policy/Coverage Updates

CMS ~3.6% Payment Cut: Review of estimated 3.6% reduction in the final fee schedule. Click here for more detailsapta/2021/01/06/conversion-factor-adjustment

97014 Estim, unattended                       97012 Mechanical traction                   96004 Gait analysis, instrumented

96004 Motion analysis, instrumented      97033 Iontophoresis                    97016 Vasopneumatic compression

Utilization Management

  • UnitedHealthcare is transitioning to InterQual criteria for all benefit plans effective May 1, 2021. InterQual criteria are nationally recognized, evidence-based clinical criteria that we’ll use for utilization management for all our benefit plans.  February 1, 2021 Announcement  *APTA is working on obtaining the guidelines for review. As providers, you may receive additional information/intel before the transition. If so, please share what you can with us. Contact: Elise Latawiec at eliselatawiec@apta.org*

 

  • Medicare Advantage and Medicaid: If you’re a physical therapy provider facing challenges or delays in obtaining authorization to evaluate or treat your Medicare Advantage and Medicaid patients, we encourage you, and your patients, to contact 1-800-Medicare. Afterwards, contact advocacy@apta.org to alert us to your complaint and tracking number — you’ll help our advocacy efforts with payers and oversight entities, including CMS. 

Dealing With a Problematic Medicare Advantage and/or Medicaid Utilization Management Program? Contact Medicare — and Then Email APTA

  • APTA General Template Letter: The attached template letter has been developed for providers to share with patients when utilization management policies are interfering with access to reasonable and necessary care. Patients may use this letter to reach out to their employer or human resource manager regarding the challenges.  Patient Letter to Employers re Access to PT Services

Update to CMS Payment Calculations Further Eases Impact of Cut

 
What began as a projected 9% cut in payment to PTs under Medicare and was later reduced to an estimated 3.6% cut may be whittled down even further thanks to a recently announced change to how payment is calculated. The change comes by way of an adjustment to the conversion factor, the multiplier applied to relative value units to determine Medicare Part B payment amounts. That figure changed from CMS' planned $32.41 (precise number: $32.4085) rate to $34.89 ($34.8931) for 2021. — a 3.32% decrease compared with the 10.2% then estimated 3.6% reduction in the final fee schedule.
Click here for more detailsapta/2021/01/06/conversion-factor-adjustment
 
In a few instances, the new payment levels could even result in slight increases, particularly for PTs conducting an evaluation or reevaluation. For example, in 2020, use of evaluation CPT codes 97161-97163 resulted in a payment of $87.70; that payment increases to $101.89 in 2021. Similarly, payment for reevaluation CPT code 97164 will also increase this year, from $60.30 in 2020 to $69.79. (Note: actual amounts vary by locality).
 

PHE Practice Expense Code 99702

 
This AMA code is for reporting expenses incurred as a result of the necessary public health response to a Public Health Emergency, in this case the COVID-19 Pandemic.
RI Payment Policy Committee continues to run a pilot trial of billing this expense code. To date, no local or national insurers have reimbursed - Medicare, UHC, RI Blue Cross and NHP RI.  
Articles for your reference:
Full November 4th Article: Click Here: Apta.org/news November 4th CMS coding-decision-99072
More detailed review of code utility, click here for Sept. APTA article https://www.apta.org/news/2020/09/25/new-cpt-code-covid
 

Reminders:

 
Extension of the Moratorium on Medicare’s -2% Sequestration:  
The CARES Act signed into law in March of 2020, suspended the planned payment adjustment percentage of -2% applied to all Medicare Fee-For-Service (FFS) through December 31 As a result, PTs experienced a 2% boost to their payments beginning in April 2020. Additional efforts supported by the APTA have again extended this moratorium to March 31, 2021 through the Consolidated Appropriations Act, 2021, signed into law on December 27th.
 
NHP RI : Policy update for 2021
Effective January 1, 2021 visit limits to 24 sessions. Click link for Policy details.  
 
RI BCBS Telemedicine/Telephone Services: Updated Telemedicine Policy making Telehealth Permanent.  Effective 1/1/21
(As a result, BCBSRI’s Temporary Telemedicine/Telehealth and Telephone Services During the COVID-19 Crisis – Effective 3/18/20 policy will no longer be in effect for dates of service on or after 1/1/2021)
For updated Telemedicine Policy information click HERE: Telemedicine/Telephone Services for Commercial Products - Effective 1/1/2021
 
 

 

NCCI Edit information - 

 

NCCI Edit Updates

 

National Correct Coding Initiative: Commercial Payor Summary of Adoption of recent CMS NCCI Edit deletion:

 

  • Humana will adopt new CMS NCCI edit files and apply retroactive to 1/1/20.  They will not automatically reprocess claims but will re process if claims are resubmitted.
  • CIGNA will not retroactively process claims but will acknowledge the NCCI edits deletions starting 1/1/2021.
  • Aetna will retroactively reprocess claims to 1/1/2020. However, providers DO NOTneed to resubmit their claims. Aetna will auto-process the claims. Aetna has indicated this could take several month.
  • Humana will retroactively reprocess claims to 1/1/2020. However, providers DO need to resubmit their claims.

 

Currently, we're waiting for clarification from Anthem regarding their response to APTA.

 

CMS Releases Coding Edits With Possible Good News for PTs CMS has released the list of Medicare National Correct Coding Initiative procedure-to-procedure edits that will take effect Jan. 1, 2021. Many of the PTP edits for common physical therapy code pairs have been deleted; APTA staff are currently reviewing the files in detail to identify all the changes. One early finding: We’ve determined that the problematic edits that prohibited the billing of codes 99281-99285 with codes 97161-97164 have been deleted. We’ll share more detailed information about all the changes as soon as possible. The updated list of PTP edits can be found at the CMS NCCI coding edits page.

Final Rule CY 2021 2 Big Picture Takeaways and an overview:

Big picture, takeaway 1: Saying its options are limited by law, CMS is moving ahead with a severe cut to physical therapist services. Despite intense pressure from a long list of professional associations, patient advocacy groups, and members of Congress, the U.S. Centers for Medicare & Medicaid Services has released a final physician fee schedule for 2021 that results in significant cuts to many codes used by nearly three dozen professions, with physical therapy, occupational therapy, and speech-language pathology facing an estimated 9% overall reduction. According to CMS, those reductions had to be made in order to increase payment for evaluation and management codes, known as E/M codes, while maintaining budget neutrality required by law. ). It's now up to Congress: CMS has finalized cuts, making it more important than ever to urge lawmakers to support H.R. 8702. The cuts proposed by CMS in 2019 will take effect Jan. 1, 2021, but a bill in Congress could offset the damage. Contact your legislators to advocate for adoption of the Holding Providers Harmless From Medicare Cuts During COVID-19 Act of 2020, and join us for a virtual #FightTheCut rally on Dec.  

In this review: CY 2021 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Medicare Policies (final rule), CMS fact sheet Effective date: Jan. 1, 2021

Big picture, takeaway 2: CMS says it doesn’t have authority to permanently add PTs and PTAs as authorized Medicare providers for real-time telehealth services (but will allow e-visits, virtual check-ins, and remote assessment of video or images by PTs). The rule will allow these three forms of non-face-to-face physical therapy services to continue to qualify for payment — approaches that were among the first to be permitted for PTs and facility-based therapy providers in the early days of the coronavirus public health emergency. For now, however, opportunities for real-time telehealth services once again will be unavailable to PTs and PTAs after the end of the PHE.

Both proposals from CMS highlight the need for federal legislation that allows for changes advocated by APTA and multiple patient and stakeholder groups. APTA is urging members to join in its efforts to push for congressional support of H.R. 8702 to stop the detrimental cut from taking effect.

 

 

Telehealth in Physical Therapy

Despite APTA’s successful advocacy that has allowed PTs and PTAs to engage in services delivered via real-time telehealth during the public health emergency, CMS doesn't provide a way for that ability to remain once the emergency ends. CMS states in the final rule that at the conclusion of the PHE for COVID-19, payment for Medicare telehealth services will once again be limited by the requirements of section 1834(m) of the Social Security Act. 

In the proposed rule, now made final, CMS created a third category of criteria for adding services to the Medicare telehealth services list on a temporary basis — a category that includes services for which there is likely to be clinical benefit when furnished via telehealth, but for which there is not yet enough evidence to permanently add the services under Category 1 or Category 2. Any service added under Category 3 will remain on the Medicare telehealth services list through the calendar year in which the public health emergency ends. Initially, physical therapy codes weren't included in the temporary Category 3 list; due to APTA advocacy efforts the final rule does include the following codes: 97161- 97164, 97110, 97112, 97116, 97535, 97750, 97755, 97760, and 97761.

It’s important to keep in mind that despite the addition of these codes to the telehealth list on a temporary, Category 3 basis, that doesn't mean PTs and PTAs will be eligible to furnish and bill for telehealth services through the end of a calendar year should the PHE ends before that. Bottom line: Barring congressional action — and even with these codes added to this list on a temporary basis — during the time between the end of the PHE and the remainder of the calendar year in which the PHE ends, telehealth services can only be furnished by a PT if billed incident to the professional services of a physician or practitioner who is authorized to furnish and bill for telehealth services, provided that the “incident to” requirements are met.

Clarification of Existing PFS Policies for Telehealth Services
The final rule also clarifies that if audio/video technology is used in furnishing a service when the beneficiary and the practitioner are in the same institutional or office setting, then the practitioner should bill for the service furnished as if it was furnished in person, and the service would not be subject to any of the telehealth requirements under the Medicare telehealth statute and regulations.

Direct Supervision Established Through Virtual Presence
In an effort to limit COVID–19 exposure for the duration of the PHE, in the spring, CMS adopted an interim final policy that revises the definition of direct supervision to include virtual presence of the supervising physician or practitioner using interactive audio/video real-time communications technology. This temporary policy applies to private practice PTs and PTAs.

In the proposed fee schedule, CMS proposed to extend this policy until the end of the calendar year in which the PHE for COVID-19 ends — an expansion from the original policy set in place at the beginning of the PHE. CMS finalized that proposal, which means direct supervision can be provided using real-time, interactive audio and video technology through, at the very earliest, Dec. 31, 2021. If the PHE extends beyond 2021, the cutoff for remote supervision allowances would move to the end of whatever year the PHE ends.

CMS also clarified that telehealth services may be furnished and billed when provided incident to a distant site physicians’ (or authorized NPP’s) service under the direct supervision of the billing professional provided through virtual presence.

Communication Technology-Based Services
The final rule allows for forms of remote services by PTs on a permanent basis, designating them as “sometimes therapy” codes — namely, e-visits (G2061-G2063), remote assessments of recorded content or images from an established patient (G2010), and virtual check-ins (G2012). CMS states in the final rule that it is replacing HCPCS codes G2061-G2063 with CPT codes 98970-98972. CMS also developed HCPCS codes identical to the existing virtual therapy codes (G2010 and G2012). These are G2250 and G2251, respectively.

Also Notable in the Final Rule

  • PTAs and OTAs are permitted to provide maintenance therapy in Part B settings. In another change first adopted during the public health emergency thanks to APTA’s advocacy, CMS is adopting a permanent change that allows PTs and OTs to delegate maintenance therapy to their supervised assistants in Part B settings. PTs still are expected to abide by existing rules that require use of the CQ modifier when services are provided "in whole or in part" by the PTA.
  • Payment for physical therapy evaluations and reevaluations get a bump — but not enough to offset the overall damage done by the lower conversion factor. CMS acknowledges that physical therapy CPT codes related to evaluation and reevaluation are similar to the E/M visit code set, and will increase the work RVU for evaluation codes 97161, 97162, and 97163 from 1.2 to 1.54. The work RVU for reevaluation (97164) rises from 0.75 to 0.96.  Bottom line: Despite the conversion factor reduction, in the case of these codes, payment would increase in 2021. But that's by far the exception: For many other codes in the physical therapy code set the lowered conversion factor ultimately results in reductions in Medicare payment.
  • Codes associated with remote physiologic monitoring would remain out of reach for PTs. Despite persistent advocacy to the contrary, CMS is sticking to its opinion that CPT codes 99091, 99453, 99454, 99457, and 99458 — all associated with remote physiologic monitoring — are E/M codes that can be billed only by providers who can bill for E/M services. PTs aren't on that list.
  • Flexibility with medical record documentation. CMS clarified that PTs who are authorized to furnish and bill for their professional services may review and verify (sign and date) the documentation in the medical record for the services they bill, rather than re-document notes in the medical record made by therapy students or other members of the medical team. While any member of the medical team may enter information into the medical record, only the reporting therapist may review and verify notes made in the record by others for the services the reporting therapist furnishes and bills. The information entered into the medical record must support that the furnished services are reasonable and necessary.
  • KX modifier threshold amount for 2021. 2021 Annual Update of Per-Beneficiary Threshold Amounts: CMS has released the 2021 Annual Update of Per-Beneficiary Threshold Amounts. For CY 2021, the KX modifier threshold for physical therapy & speech-language pathology services combined is $2,110; the KX modifier threshold for occupational therapy is $2,110. The targeted medical review threshold remains at $3,000 until CY 2028, at which time Medicare will update it based on the Medicare Economic Index. https://www.apta.org/article/2020/12/02/final-2021-pfs
  • The MIPS portion of the rule will be published in the coming days

 


 

In Case you Missed it: On Friday, October 2, HHS Secretary Azar announced he is extending the public health emergency declaration, effective October 23, 2020 for the 3rd time. 

The PHE will be up for renewal again January 23rd (every 90 days).

This renewal, means that PTs and PTAs in private practice and facility-based physical therapy providers will:

  • continue to have access to the temporary Medicare regulatory waivers, and
  • new rules that afford providers flexibility to respond to COVID-19 pandemic, including telehealth coverage.

 

NCCI Edits Reinstated Oct. 1st: Strong effort by APTA

  • APTA has been engaged with several insurances (Cigna, Aetna, Humana, BX) to eliminate claims being denied or flagged for use of the 59 modifier.  
  • APTA has submitted requests to CMS for permanent elimination
  • Ongoing education on use of the edits and supporting documentation requirements on the APTA website.
  • We encourage providers who do experience high appeal overturn rates to contact the payer and/or APTA to see if the provider can get exempted from this policy.

Summary of common Therapy Codes affected: https://ppsapta.org/sl_files/ED27B611-A00A-A32C-23D0678E332A6EE9.pdf

 


Click here for Local and National Telehealth Guidelines 

(updated 2/17/21)
What you need to know on billing and providing telehealth


 

RI BCBS

BCBS Rhode Island posts TEMPORARY Cost Share Waiver for Treatment of Confirmed Cases of COVID-19 During the COVID-19 Crisis 1-6-2021 
  • Update – No Cost share for hospital outpatient physical therapy when patient has a dx of COVID19.   

 

 

Telemedicine/Telephone Services: Updated Telemedicine Policy making Telehealth Permanent.  Effective 1/1/21

(As a result, BCBSRI’s Temporary Telemedicine/Telehealth and Telephone Services During the COVID-19 Crisis – Effective 3/18/20 policy will no longer be in effect for dates of service on or after 1/1/2021)

For updated Telemedicine Policy information click HERE: Telemedicine/Telephone Services for Commercial Products - Effective 1/1/2021

At a glance:

  • BCBSRI will continue to reimburse telemedicine encounters at 100% of the in-office allowable as outlined in their policy per plan.
  • Will cover Synchronous 2 way audiovisual telemedicine for Physical Therapy Services – NOT Phone. 
  • Audio and Video telemedicine will require: POS02 and Modifiers 95  
  • Lose cost share waivers
  • Current CPT codes listed include most standard PT CPT codes.    
    • RIAPTA working for you – Upon review of covered codes, CPT 97530, Therapeutic Activities, was omitted.  RI Blue Cross was contacted and reports this was in error.  CPT 97530 will be included on list of TH covered services. 

 

Blue Cross & Blue Shield of Rhode Island (BCBSRI) has extended its  Temporary Telemedicine/Telehealth and Telephone Services During the COVID-19 Crisis policy until December 31, 2020.

BCBSRI is taking this step in an effort to ensure members have access to the healthcare services they need virtually, as well as providing certainty to network providers that they will be able to continue to provide telemedicine services until the end of the year. Full details of the policy are available for review here.   


 

BCBS Telemedicine MODIFIER Updates:

As of 10/1/2020 For claims filed on or after October 1st BCBSRI will require the following modifiers to be appended:

  • Audio and Video telemedicine will require: POS02 and Modifiers 95 + CR , 95 in the first position and CR in the second.   
  • Telephone only requires: POS02 Modifier CR  

 

Local and National Insurers extend coverage benefits for Telemedicine services:

BCBS of RI, Cigna, Aetna, Humana, Anthem – Extended to December 31st

Click here for all details: United Health COVID Update

See updated Telemedicine Reference Guide above.

 

NHP of Rhode Island– Adopts Medicare’s PTA, OTA CQ, CO modifiers

Medicaid, Integrity and Commercial now required for PTA’s and OTA’s respectively

Click here for updated policy information: nhpri.org/2020/Outpatient-PT OT Rehabilitation-Services10.01.20.pdf

 

NCCI Edits Reinstated Oct. 1st: Is your practice ready?

Effective October 1, CMS reversed and reinstated previously deleted coding "edits"  for code pairs that represent common and appropriate physical therapy practice.

A strong advocacy effort by APTA members and others helped to convince CMS to reverse that decision in April. Now CMS has moving ahead, providing no opportunities for input on its decision to reinstate.

Click here for APTA news article: APTA NCCI Coding Edits

PPS Summary of common Therapy Codes affected: https://ppsapta.org/sl_files/ED27B611-A00A-A32C-23D0678E332A6EE9.pdf

Click here for CMS NCCI Edit detail: CMS NCCI-Coding-Edits

 

What is new with the PHE Practice Expense Code 99702?

What’s this Code again? This new AMA code is for reporting expenses incurred as a result of the necessary public health response to a Public Health Emergency, in this case the COVID-19 Pandemic.

According to November 4th APTA News Article:

  • CMS : The Good/Bad News - CMS has added it to its physician fee schedule, BUT it was given a “B” status (CMS "B" Status) therefore is not reimbursable by CMS. We can bill to CMS but will not be reimbursed. 
  • According to Kara Gainer, JD, Director of Regulatory Affairs for the APTA, ..”the commercial payment landscape is varied: some payers had already adopted this approach, others were waiting to see where Medicare landed, while still others are in fact paying on the code”
  • We are staying on top of specific payor policy for this code.  Stay tuned!

For full November 4th Article: Click Here: Apta.org/news November 4th CMS coding-decision-99072

For a more detailed review of code utility, click here for Sept. APTA article : https://www.apta.org/news/2020/09/25/new-cpt-code-covid

 

Documentation:

APTA Recorded Webinar: Skilled Physical Therapy Documentation Rules and Best Practices – 45 min http://communities.apta.org/p/do/sd/sid=6995

  • Overview: APTA staff review Medicare’s physical therapy documentation requirements and discuss documentation best practices. They discuss how to overcome the documentation concerns reported by payers and review some of the standardized tests that assist physical therapists in quantifying documentation and goals. Finally, APTA staff review the differences between restorative and maintenance therapy and how to ensure your documentation reflects the medical necessity of both.
  • Content included: 1. Recorded webinar: available on the Learning Center: https://learningcenter.apta.org/student/mycourse.aspx?id=ef73cf5d-222c-461f-9cf9-9770cb12ea12  2. Power point of the presentation 3. One sheet hand out: "Defending the documentation"

 

 

 

 APTA

RIAPTA Liberty Square Group
4 Liberty Sq, #500
Boston, MA 02109
(857) 702 – 9915
riapta@libertysquaregroup.com