CMS Reinstates Therapy NCCI Edits
The Centers for Medicare and Medicaid Services (CMS) has reinstated many of the procedure-to-procedure (PTP) edits, known more commonly as the National Correct Coding Initiative (NCCI) edits, for physical therapy, occupational therapy, and speech therapy outpatient therapy services that they had deleted earlier this year. The reinstated NCCI edits were published by CMS on September 1, 2020 and become effective with dates of service beginning on October 1, 2020.
CPT codes affected include, but are not limited to, the following:
- Biofeedback codes (CPT codes 90912 and 90913)
- Speech therapy evaluations (CPT codes 92521-92524)
- Speech therapy treatment and treatment of dysphagia codes (92507 and 92526)
- Evaluation for a speech generating device (92607)
- Programming and training for speech generating device (92609)
- Physical and occupational therapy evaluations and reevaluations (CPT codes 97161- 97168)
- Aquatic therapy
- Therapeutic activities
- Assistive technology assessment
- Orthotic management and training
- Prosthetic training
In addition, with CMS reinstating many of the NCCI edits, most likely, this will have a negative impact on outpatient therapy providers who submit claims to Aetna, Anthem BC, Humana and others who do not pay the column 2 CPT code when billed on the same day as the column 1 CPT code even when the provider appends modifier 59 correctly.
To access Gawenda Seminars & Consulting NCCI edit reference sheet that provides the physical, occupational and speech therapy NCCI edits in an easy-to-read format, click HERE.
Examples of the reinstated NCCI edits include, but are not limited to, the following:
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Once again, to access Gawenda Seminars & Consulting NCCI edit reference sheet that provides the physical, occupational and speech therapy NCCI edits in an easy-to-read format, click HERE. I hope you found this article helpful. Thank you for your Gold Membership!
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Hi Rick, so now that CMS has put the edits back in, does my billing department need to do anything different when they post charges? are there any modifiers they have to use differently starting Oct 1?
Yes! You may need to use Modifier 59 on some CPT codes on your claim form.
After reviewing the new CCI edits, it appears that we can still use some of the coding pairs (with a 59 modifier) that were prohibited earlier this year. For example, we can use 97530 with 97116 as long as there is a 59 modifier on it. Is that correct?
Yes
Hello Mr. Gawenda! So am I correct in reading that we again CANNOT bill for Manual Therapy (97140) on the same day we do the PT Evaluation (97161, 97162, 97163) Unless we append the -59 Modifier to the 97140?
(I’m sure everyone agrees this is a terrible edit for the Manually focused Outpatient Physical Therapist)
Correct!
Rick, I can’t seem to find the complete NCCI edits eff 10/1/20. Has CMS not published the complete list yet? If so, where can I find it?
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits
Can we still bill Eval with a TA on the same day? Or will we have to use a modifier 59 when we bill?
Please look at the current version of NCCI edits as well as Version 26.3 that becomes effective on October 1, 2020.
https://gawendaseminars.com/medicare-cms-cci-edits/
Starting 10-1-20, can a PT/OT bill an Eval and theract the same day, and be reimbursed for the theract? I don’t see on the cheat sheet that a modifier is required in this combination of codes. Thank you as always!
I published this article back on January 24, 2020
https://gawendaseminars.com/update-on-evaluation-and-therapeutic-activities-same-day/
Can we use MT and TA on the same day as an Eval if we put a modifier 59 on MT? Thanks
Please look at the current version of NCCI edits as well as Version 26.3 that becomes effective on October 1, 2020.
https://gawendaseminars.com/medicare-cms-cci-edits/
“…this will have a negative impact on outpatient therapy providers who submit claims to Aetna, Anthem BC, Humana and others who do not pay the column 2 CPT code when billed on the same day as the column 1 CPT code even when the provider appends modifier 59 correctly.”
I have three questions about this statement:
What is the column 1 and 2 CPT code?
How do we get paid from Humana if we code 97113-aquatics, if they aren’t paying for it?
Can we code another unit in the water; ie – 97112, 97530, etc, in the water so we can get paid from Humana?
We do lots of 97113 coding for aquatics for Humana. We are not getting paid from some Humana products. We have appealed and appealed but to no avail!
Help!
You can read my FAQs on NCCI edits at https://gawendaseminars.com/faq/cci-edits-ptot/
You can also read this article from June 2020: https://gawendaseminars.com/ncci-edits-and-version-26-2
These NCCI edits apply to Critical Access Hospitals Correct?
Yes