[Updated] CMS Implements Surprise Coding Edits Effective January 1

[Updated] CMS Implements Surprise Coding Edits Effective January 1

Procedure to Procedure (PTP) edits (formerly called CCI edits) are updated by CMS quarterly. PTP edits are established by CMS and dictate when certain CPT / HCPCS codes can be billed together on the same date of service by appending modifier 59 and when two codes cannot be billed together on the same date of service, or rather, if the two codes are billed together on the same date of service, which of the two codes will not be paid.

With the January 2020 update, there are several modifications to the PTP edits that affect therapy services:

  • First, and most problematic, effective January 1, 2020, CMS has implemented “hard edits” between CPT codes 97530 (therapeutic activities) and 97150 (group therapy) and the PT and OT eval codes (CPT codes 97161-97163 and 97165-97167). These edits cannot be bypassed via application of modifier 59. Both 97530 and 97150 are “column 1” codes in the CMS edit tables, while the PT and OT eval codes are listed in “column 2.” This means that if, for example, 97530 and a PT eval (e.g., CPT 97162) are billed on the claim on the same date of service, only CPT 97530 would be paid. Keep in mind also, that PTP edits cross disciplines – if PT bills 97530 today, then OT cannot bill (or be paid for) an evaluation today.
  • Modifier 59 is now required for CPT 97140, manual therapy, when billed on the same date of service as CPT codes 97161-97163 (PT Eval) and/or 97165-97167 (OT Eval).
  • Finally, effective January 1st, modifier 59 is not indicated as required in the CMS PTP edit tables when CPT codes 97129 and 97130 (therapeutic interventions that focus on cognitive function) are billed with any of the following CPT codes:
      • 92507, treatment of speech, individual
      • 92508, treatment of speech, group
      • 92526, treatment of swallowing dysfunction
      • 97150, group therapy
      • 97530, therapeutic activities
      • 97755, assistive technology assessment

Prior to January 1, 2020, CPT / HCPCS codes describing cognitive interventions (i.e., 97127 and G0515) required modifier 59 when billed with the aforementioned codes.

CMS guidance in the NCCI Manual, Chapter 11 continues to outline CMS’s expectations that: 1) speech-language pathologists should not report 92507 and/or 92508 on the same date of service as 97129, and 2) that if the services are provided by different types of practitioners (SLP and OT, for example), the services may be reported separately “using an NCCI PTP-associated modifier.” Providers will likely have to wait for the April update to the CCI/PTP edits to see if the edit tables are revised to match this manual guidance.

The current PTP edit tables can be accessed from the CMS website.

And, for additional information about the edits and association advocacy efforts, click here.

Holly Hester

Holly Hester is Casamba’s Senior Vice President of Compliance & Education, as well as the Compliance Officer. She provides regulatory guidance and interpretation, clinical programming and content development, education and training steerage, and compliance support for the company. As a physical therapist for more than 20 years, Holly has multi-venue clinical and management experience, giving her a unique perspective on the integration of compliance and training with therapy service delivery and clinical practice.
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