Members, did you know that one bright spot in the final 2022 Medicare Fee Schedule rule, that was pushed by APTA, is that PTs can now bill five remote therapeutic monitoring (RTM) codes related to cost, set-up, and monitoring of devices that measure patient therapy adherence and therapeutic response.
The codes were created to account for devices that allow patients to self-report, manually enter, and digitally upload non-physiologic data related to musculoskeletal system status, respiratory system status, therapy adherence, and therapeutic response. The focus of the new resource is on two sets of CPT codes: 98975, 98976, 98977, related to RTM services; and 98980 and 98981, related to RTM treatment management services.
Thankfully, although CMS excluded PTs from using these codes in the proposed 2022 fee schedule rule, APTA pushed the agency to expand use. CMS made the change in the final version of the rule, which took effect January 1, 2022.
APTA created an advisory that includes background on the codes, descriptions of each, documentation requirements, and guidance on which codes are subject to payment adjustment under the PTA differential system now in place. The resource also features clinical scenarios to help you understand the real-world application of the codes. Please use this link to educate yourself on the proper use and documentation of remote monitoring. APTA will continue to support members through updates or additional education.
In November, 2021 APTA posted the following article titled: Cohere To Take Over All MSK, Therapy Prior Authorization for Humana
Humana’s decision to rely solely on Cohere beginning Jan. 1, 2022, comes after a 12-state program rolled out this year.
On December 6th, APTA had an opportunity to meet with Cohere for a question and answer session on the new prior authorization process for Humana. This document was created by APTA payment specialists. There are answers to common questions as well as links to Cohere resources.
Please review this information to ensure you are prepared for this change effective 1/1/22.
You can lead Medicare to a code, but you can’t make it pay.
Back in September, providers were encouraged when the American Medical Association announced it had updated its current procedural terminology code set to include a code for reporting expenses incurred as a result of the necessary public health response to the COVID-19 pandemic. The code — 99072 — was a new practice expense code that describes the additional supplies and clinical staff time required to provide safety measures during a public health emergency. In the current environment, it could be used to denote expenses related to stopping the spread of the coronavirus while still providing safe in-person visits.
Cut to Oct. 27, when the U.S. Centers for Medicare & Medicaid Services put the brakes on any additional payment directly related to the new code under Medicare.
In an MLN Matters update, the agency included 99072 among several codes that were being added to the 2020 Medicare Physician Fee Schedule, but with one important caveat: The code was assigned a “B” procedure status, meaning it is a bundled code and won’t be associated with any relative value units and payment policy indicators won’t apply.
“Basically, what CMS is saying is that this code doesn’t warrant an additional payment on top of what providers are getting paid for the services rendered during that visit, ” said Kara Gainer, APTA director of regulatory affairs. “Providers can still include it on the claim, but payment will be considered ‘incident to’ the treatment being provided that day, meaning that separate payment won’t be provided.”
According to Gainer, 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.
Our advice: Check with your state Medicaid programs and commercial insurers regarding eligibility for payment and coverage of the code.
Another important tip: Should a payer not adopt coverage for 99072, don’t bill the cost associated with this code to the patient. And remember that providers must comply with state law, which could restrict the application of surcharges for additional supply expenses associated with the public health emergency.
https://www.apta.org/news/2020/11/04/cms-coding-decision-99072
As you may know, on October 1, the National Correct Coding Initiative procedure-to-procedure (PTP) edits associated with thousands of code pairs were reinstated after having been temporarily removed in early April. This includes the PTP edits for code pairs:
• 99281-99285 (emergency department E/M services) with 97161-97168 (PT and OT evals and re-evals).
These code pairs cannot be billed together, even with a modifier, as these code pairs have a status indicator of “0.” Thus, when these code pairs are billed together, only CPT codes 99281-99285 are eligible for payment.
Over the last 10 months, APTA has been advocating to CMS that they remove the edits for these code pairs. APTA most recently sent a request to CMS and the NCCI contractor in early October, wherein we again urged them to remove these edits. CMS has assured us that they are still considering our request. AOTA also has asked CMS to remove these restrictive edits.
APTA also brought our concerns about these edits to the attention of the American Hospital Association. However, AHA indicated that they had not heard from any of their member hospitals regarding concerns with these edits. Thus, we’ve been asking APTA members who work in the hospital setting to urge their hospital to reach out to AHA and ask the association to advocate for removal of these edits. In addition, we’re encouraging individual PTs and/or their hospitals to reach out to CMS and urge them to remove these edits. CMS can be contacted via: NCCIPTPMUE@cms.hhs.gov.
Some suggested talking points when reaching out to CMS:
• As a physical therapist that works in the hospital setting, I strongly recommend that CMS remove the PTP edits associated with CPT codes 99281-99285 and 97161-97164.
• The ED E/M services and physical therapy evaluation or re-evaluation do not overlap, and are always separate and distinct services if in no other way than that they are always provided by different practitioners. As stated in the CPT manual, one function of the emergency department visit is to coordinate care with other qualified health care professionals consistent with the nature of the problem and the patient’s and/or family’s needs.
• The restrictive PTP edits for CPT codes 99281-99285 and CPT codes 97161-97164 impose a significant penalty on code combinations that represent standard and necessary care, fail to align with the current practice of care, and negatively impact the ability of hospitals to implement best practices. Further, the edits prevent physical therapists from serving those in immediate distress in the emergency setting while hindering their ability to work as part of an interprofessional team.
• The physical therapy profession is responsible for managing disease and disability for individuals across the life span, optimizing movement to improve the human experience. CMS must promote policies that improve access to physical therapy, not limit it.
• To better support the effective and efficient treatment of a patient’s condition and avoid delay of a meaningful intervention, I strongly recommend that CMS remove the PTP edits for CPT codes 99281-99285 and CPT codes 97161-97164
Should you have any questions or would like additional information, please contact advocacy@apta.org
What you might not know about Preferred One’s prior authorization policy may limit reimbursement for your services.
The Payor Advocacy Workgroup APTA Minnesota (workgroup of the Payment Committee) recently met with Preferred One regarding their prior authorization policy. Currently, Preferred One does not allow retro authorization for services provided prior to an authorization request being submitted. We have heard from many members that this policy is limiting their ability to be paid for treatment provided on the day of the evaluation visit. In the meeting with Preferred One, we were informed of a specific sequence of work that, if followed, you can expect to get paid for evaluation and treatment on the first visit, if the patient and documentation meets the requirements of treatment in the Preferred One policy. Read on for valuable information.
For plans that require authorization: PreferredOne does not retroactively authorize for treatment, but will pay for treatment if deemed medically necessary via the following process.
1. Upon scheduling, notify PreferredOne of the upcoming appt for Patient X via the same communication route of requesting authorization. This serves as an alert for upcoming services.
2. If the advance alert is completed, and treatment is deemed medically necessary on day of evaluation, PreferredOne will reimburse for the treatment completed prior to authorization request completion.
3. If treatment is not deemed medically necessary, PreferredOne will not reimburse the treatment even when the advanced alert is completed.
In order to ensure payment for treatment, the following options are available:
1. Once patient is scheduled, notify PreferredOne of upcoming visit – serves as an alert that member will be coming in for services. (above process)
2. If treatment is provided on date of the evaluation, submit authorization request on same day.
3. If additional treatment is needed, do not treat patient until authorization request has been submitted. You may want to consider authorization submission as a requirement prior to scheduling subsequent visits in order to avoid denials due to lack of authorization
*The Payor Advocacy Workgroup serves APTA Minnesota physical therapists and physical therapist assistants by advocating on behalf of APTA MN and its members on issues relating to payment, payment policy, and restrictive actions by payors affecting payment of physical therapy services. The workgroup meets with the larger payors in the state on a quarterly basis.
APTA Minnesota is pleased with the decision as the $2M/$4M requirement would add additional cost for physical therapy practices that are contracted with BCBS to treat their members.
BCBS had previously announced that the minimal requirement for professional liability insurance by Physical Therapy providers will increase to $2 million per incident and $4 million aggregate, effective July 1, 2019.
APTA Minnesota is pleased with the decision as the $2M/$4M requirement would add additional cost for physical therapy practices that are contracted with BCBS to treat their members.
APTA Minnesota is pleased to inform members that Blue Cross and Blue Shield of Minnesota announced a new Appeals Policy which includes a change to the prior authorization requirement for physical therapy services. The updated policy, Final OP Therapy and Chiro PA Changes Bulletin P34-19.pdf can be accessed at the BCBS MN website using the link http://bit.ly/2Ud3AMk
