Next Event: NCCI Edits & Modifier 59: Version 31.2
Date: June 26,2025
CMS Releases Proposed Rule for Calendar Year 2020
On July 29, 2019, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule for calendar year (CY) 2020 for services paid under the Medicare Physician Fee Schedule (MPFS). This proposed rule does impact providers of outpatient physical, occupational and speech therapy services in all outpatient therapy settings that does include private practices, hospital outpatient departments (including Medicare beneficiaries under Observation status and in the Emergency Department and do not get admitted to the hospital), skilled nursing facilities, rehabilitation agencies, comprehensive outpatient rehabilitation facilities and home health agencies providing outpatient therapy in a Medicare beneficiaries home.
Highlights of the proposed rule include:
- Proposing to revise the regulations at §§ 410.59 and 410.60 discussing the annual therapy threshold, use of the KX modifier, and the targeted medical review threshold
- CQ/CO Modifiers to be appended to CPT codes for services provided in whole or in part by a PTA or OTA
- To add a requirement that the treatment notes explain, via a short phrase or statement, the application or non-application of the CQ/CO modifier for each service furnished that day
- PTA and OTA Payment Changes in 2022
- New CPT codes for trigger point dry needling
- New Biofeedback CPT codes
- New Health and Behavioral Assessment and Intervention CPT codes
- Discussing the 2 new Cognitive Function Intervention CPT codes
- Work relative value unit (RVU) for CPT codes 97597 and 97598
- Proposing an Active Status for CPT codes 97607 and 97608
- Proposing a work RVU of 0.40 for CPT code 97610
- Online Digital Evaluation Service HCPCS Level II Codes
- 2020 Medicare Physician Fee Schedule Conversion Factor
- 2020 MIPS Program
Revising Regulations at §§ 410.59 and 410.60 The content here is for members only log in here or sign up. CQ and CO Modifiers The content here is for members only log in here or sign up. de minimis Standard for CQ and CO Modifiers The content here is for members only log in here or sign up. Documentation Requirements to Support Use of or Non-use of CQ/CO Modifiers The content here is for members only log in here or sign up. PTA and OTA Payment Changes in 2022 The content here is for members only log in here or sign up. New CPT Codes for Trigger Point Dry Needling The content here is for members only log in here or sign up. Biofeedback CPT codes The content here is for members only log in here or sign up.
New Health and Behavioral Assessment and Intervention CPT Codes The content here is for members only log in here or sign up.
Hello,
For Revising Regulations at §§ 410.59 and 410.60 in simple terms, is CMS looking to create a new threshold cap based on the KX or are they trying to clarify the use of the KX. Having a little trouble understanding this proposal. Thank you.
I have just updated the article with more detailed information.
Are you aware of any group fighting the 15% decrease in reimbursement for PTA’s/OTA’s? This is significant and it doesn’t seem like it is getting much attention. Not only will this affect a business financially but it looks like additional documentation will be required for every medicare patient seen whether a PTA/OTA provides any services or not. Your article states CMS is proposing required documentation explaining the application or non-application of the CQ/CO modifiers for each service furnished that day. The broken record continues “lower reimbursements and additional documentation”.
I can tell you our professional organizations are fighting this issue with CMS. Are you a member? You can also submit comments to CMS by the deadline to submit comments which is September 27, 2019.
Can you please clarify this for me? The way that I read your information above is that the PTA/OTA changes that start 1/1/20 will apply to Critical Access Hospitals and the changes scheduled to occur on 1/1/22 will not apply to Critical Access Hospitals. Am I interpreting this correctly? Please advise.
Since CAHs are not paid under the Medicare Physician Fee Schedule, the therapy assistant modifiers will not apply to CAHs. I am hoping that CMS will clarify in the final rule CAHs will not need to use the CQ and CO modifiers beginning January 1, 2020. The final rule is due to be released in early November.
Not sure if you can answer this directly but these are for standard Medicare patients like it was for G codes–do you know if Medicare supplements, Medicaid, or commercial insurances are following suit. Reason I am asking wondering if we can build into our EMR to drop the modifiers when they are providing the care–but assume we only want to have on standard Medicare??? Thank you!
The proposed rule addressing the new PTA and OTA modifiers only applies to traditional Medicare and no other insurance carriers. With that said, don’t me surprised if other insurance carriers also adopt the new modifiers in the future.