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[UPDATED] CMS Removes 97530/97150 and PT/OT Eval Coding Edits Effective January 1

[UPDATED] CMS Removes 97530/97150 and PT/OT Eval Coding Edits Effective January 1

Procedure to Procedure (PTP) edits (formerly called CCI 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. These edits are updated quarterly – in January, April, July and October.

With the January 2020 update, there were several modifications to the PTP edits that affect therapy services. The most surprising and problematic was the implementation of “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 were not able to be bypassed via application of modifier 59, and meant that if, for example, 97530 and a PT eval (e.g., CPT 97162) were billed on the claim on the same date of service, only CPT 97530 would be paid. These edits put the industry in an uproar – particularly because they came out of the blue and made no sense from a care delivery standpoint. It didn’t take long for the industry’s voice to be heard.

Capitol Bridge, CMS’ NCCI contractor, responded to advocacy letters from therapy industry associations (including APTA, AOTA, NASL, and NARA) and reported on Friday, January 24, that CMS would remove the PTP edits for the PT and OT evaluation codes and 97530 or 97150 that became effective 1/1/2020.  CMS posted updated PTP edit tables to their website on 2/3/2020, and the problematic edits were removed.

In a February 5 communication with APTA, Capitol Bridge stated CMS had instructed the MACs to implement the revised edit files and make claim adjustments and that providers should:

      • Check with their MAC about claim adjustments,
      • Appeal claims denied due to the edits to the MAC, or
      • Resubmit claims as permitted by the MAC.

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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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