Many provides have a good understanding of the National Correct Coding Initiative (NCCI) edits utilized by the Centers for Medicare and Medicaid Services (CMS) as well as other commercial insurance carriers, including some workers compensation carriers. However, most providers of outpatient therapy services are either unaware or lack a solid understanding of CMS’ medically unlikely edits (MUEs). In this article, I will answer the following questions: What are medically unlikely edits (MUEs)? What outpatient therapy practice settings does CMS apply MUEs to? Are there different MUEs for a private practice (submit claims on a 1500-claim form) and a facility-based provider

One of the most common topics I provide consulting services to my clients on is in regards to how to bill for an evaluation for an orthosis. Unfortunately, there is not just one answer as my answer will depend on at least 2 factors; what is your practice setting and what insurance does your patient have. In this article, I will provide the answers to the most common questions I receive in regards to the billing for an evaluation for an orthosis under an outpatient physical or occupational therapy plan of care. QuestionWhat are L Codes? Answer QuestionCan a physical

I am receiving many questions regarding what is the proper billing when a patient is referred to either outpatient physical therapy or occupational therapy for the purpose of an orthosis. In this article, I will answer this question from 2 perspectives. I will first address when a patient is referred for a one-time visit for an orthosis and secondly, provide the answer for when a full evaluation is required to develop the appropriate treatment plan in addition to an assessment related to determining the specific orthosis required for the patient. First, we need to provide the CPT code and description

On December 1, 2020, the Centers for Medicare and Medicaid Services (CMS) released the final rule for services paid under the Medicare Physician Fee Schedule (MPFS). This would include outpatient physical, occupational and speech therapy services provided in all outpatient therapy settings except for a critical access hospital. Highlights of the final rule include, but are not limited to, the following: 2021 Medicare Conversion Factor and 9% Payment Reduction Accessing the 2021 Relative Value Units (RVU’s) for Each CPT Code 2021 Annual Therapy Threshold Dollar Amount Student Documentation in the Medical Record Maintenance Therapy Provided by PTA’s and OTA’s Communication-Based

On June 15, 2020, I published an article where I answered some of the more common questions I receive regarding the National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits as they pertain to outpatient physical, occupational and speech therapy services. That article led to additional questions that I will provide answers to in this article. QuestionDoes the Medicare program pay for CPT code 97750 (Physical performance test or measurement) on the same day as a physical therapy or occupational therapy evaluation or reevaluation? Answer QuestionDoes the Medicare program pay for CPT code 97755 (Assistive technology assessment) on the same day

The Centers for Medicare and Medicaid Services (CMS) has released the calendar year (CY) 2021 Proposed Rule for services paid under the Medicare Physician Fee Schedule (MPFS). This would include outpatient physical, occupational and speech therapy services provided in all settings (private practice (both therapist-owned and physician-owned, skilled nursing facilities doing Part B, comprehensive outpatient rehabilitation facilities, rehabilitation agencies, home health agencies providing Part B therapy services in the home and hospital outpatient therapy departments). This proposed rule would not apply to outpatient therapy services provided by critical access hospitals (CAHs) since CAHs are not reimbursed under the MPFS. Highlights

This article was updated on May 28, 2020 Humana will now cover telehealth services for outpatient therapy services provided by physical therapists, physical therapists assistants, occupational therapists, occupational therapy assistants and speech-language pathologists. Humana states they will always follow the Centers for Medicare and Medicaid Services (CMS) telehealth or state-specific requirements that apply to telehealth coverage for our insurance products. Since CMS now covers telehealth when provided by physical therapists, physical therapists assistants, occupational therapists, occupational therapy assistants and speech-language pathologists in all outpatient therapy settings (both private practice and institutional settings), at minimum, Humana will now cover the same.

This article was updated on July 23, 2020 due to Secretary Azar extending the Public Health Emergency due to the COVID-19 pandemic. This article was updated on June 23, 2020 due to CMS clarifying if a practitioner can be out of the country and provide a telehealth visit to a Medicare beneficiary in a state where the practitioner is licensed in. See below for the question and the answer. This article was updated on May 27, 2020 due to the Centers for Medicare and Medicaid Services expanding telehealth coverage for outpatient therapy services to include institutional providers. Please see questions