Billing Therapeutic Activities Same Day as an Evaluation
Effective with dates of service on and after January 1, 2020, the Centers for Medicare and Medicaid Services (CMS) will
Is there a “work-around” to this issue?
Can I count the evaluation time under therapeutic activities?
Can I provide other treatments the same day as an evaluation?
Do these NCCI edits apply to all insurance carriers, including Medicare Advantage plans
Can any insurance carrier, Medicaid plan or Medicare Advantage plan implement the NCCI edits?
How do I know if an insurance carrier, Medicaid plan or Medicare Advantage plan has implemented the NCCI edits?
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Would this apply in a Critical Access Hospital for outpatient, but billing on a UB-50?
Are you sure you are billing on a UB-50? You might want to check with your billing department.
Will Medicare pay for the ADL/Self Management code (97535) for PT? We have had prior denial with BC insurance stating it was an OT code so we stopped using it in general and went to Therapeutic Activities for positioning and transfer training to help a patient self manage their pain.
PT’s are qualified to provide self care and home management activities and bill CPT code 97535. With that said, insurance carriers can decide which CPT codes they will pay for and by which discipline.
We are also the understanding that Therapeutic Group (97150) was also part of this change. Was there any advance notification sent out by CMS of this change to allow for a comment period?
I have looked on the CMS website and could not find any transmittals regarding this change.
CMS does not accept public comments on NNCI edits and proposed changes.
Would this also apply to Medicare patients being seen in the inpatient (acute) setting and billed under medicare A?
These edits apply to outpatient therapy. In true inpatient acute care, you do not bill or get paid via CPT codes. You are paid via DRGs.
Billing Medicare on UB04 requires the GP and GO modifiers as well. Are we to understand that these modifiers are not built into the exclusions? For example: would it allow the 97530 GO to be billed for OT and then the PT evaluation to be billed with 97161 GP on the same date of service? Logically these modifier should separate the two, no?
They never have. The CMS system does not recognize GP and GO for the purpose of NCCI edits.
If I submit a claim for a date of service in December 2019, am I still able to bill for Physical therapy evaluation and Therapeutic activities on the same day? If so, do I have to append modifier 59? I just started doing Part B so I’m still gathering information.
The edits are effective with dates of service on and after January 1, 2020.
Will this apply to Critical Access Hospitals billing on the UB-04?
sorry if this was asked already, but how do we handle if the patient is seeing both PT and OT (hospital-based OP).
if PT performs therapeutic activities and the OT does an evaluation on the same day – how would we bill if there is no other appropriate code to use for the services provided? do we bill both knowing that we will not be paid for one of them? It would seem the only way around this would be to see patients on different days, which is not good for patient convenience or patient experience.
That is a decision your organization will need to make.
Hello! Thank you for this information.
Your website states that if both Therapeutic Activities and a PT/OT Evaluation are billed on the same day, that only the Therapeutic Activities will be reimbursed. On WebPT, they state that the Evaluation will be reimbursed. Can you please clarify?
I am correct.
our Eval was denied.
and it should have been.
Could you explain to me why there is a time frame end date of 3/31/2020 for this NCCI edit?
Because Version 26.1 will become effective April 1, 2020 and be in effect through June 30th. The NCCI edits are updated quarterly.
Does this apply to a re-eval with therapeutic activity as well?
Please look at the NCCI edits for your answer.
Does this effect SNF billing ? Medicare A?
Managed care? Medicaid?
NCCI edits apply to Medicare patients receiving outpatient therapy services provided in all therapy settings.
Just FYI, I have had BCBS commercial plan deny my eval when billed with 97530 due to NCCI edits.
If PT evals on Monday and OT evals on Tues. Can PT bill therapeutic activity on Tues when OT is billing an eval?
If billing on a UB-04 claim form, no. The eval will not be paid.
Is this no longer the case with the new April edits? I just looked at the NCCI Edits for non-private practice settings on your website and did not see anything about PT evals and therapeutic activity requiring modifiers or not being allowed. However, I did not see this on the one for January either.
This was an updated article published on January 24, 2020. Be sure to search for articles or scroll through the Current News section as news is always changing.