Significant Changes to NCCI Edits Effective January 1, 2020
Every quarter, the Centers for Medicare and Medicaid Services (CMS) updates the National Correct Coding Initiative (NCCI) edits. This occurs on January 1st, April 1st, July 1st and October 1st of every year. The biggest changes usually occur with the January 1st edition due to new and deleted CPT codes for the new calendar year now being in effect.
Version 26.0 has been released by CMS. This version will be effective with dates of service beginning on January 1, 2020 through March 31, 2020. There are many additions and deletions to Version 26.0 that will have a significant impact on outpatient physical, occupational and speech therapy services including a physical therapy or occupational therapy evaluation not being paid if billed on the same day as a particular treatment CPT code.
Biofeedback
There are 2 new CPT codes for biofeedback training for pelvic health. They are as follows:
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Cognitive Training
There are 2 new CPT codes for cognitive training. They are as follows:
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Therapeutic Activities
There are some significant changes to the Column 2 CPT Codes when those codes are billed the same day as therapeutic activities
Column 1 Code Column 2 Code The content here is for members only log in here or sign up. Manual Therapy Effective with dates of service on and after January 1, 2020, if you bill manual therapy on the same date of service that you bill The content here is for members only log in here or sign up. Group Therapy There are some significant changes to the Column 2 CPT Codes when those codes are billed the same day as group therapy Column 1 Code Column 2 Code The content here is for members only log in here or sign up. To access the complete list of NCCI edits from CMS as well as Gawenda Seminars & Consulting “Reference Sheet” for NCCI edits that are commonly applicable to outpatient physical, occupational and/or speech therapy services, click HERE. This reference sheet will also contain other additions and deletions to the NCCI edits that will have an impact on outpatient therapy services beginning January 1, 2020. I hope you found this article helpful. Thank you for being a Gold Member!
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The cheat sheet does not currently reflect Evaluation codes for Manual Therapy (97140)—only ReEval. Based on the info provided Evaluation codes should also be included, right?
The Cheat Sheet is correct. You need to look at the evaluation codes in Column 1 and scroll over to Column 2 to see which CPT codes are considered a component of the evaluation codes.
It looks like you can still bill manual therapy (97140) with an evaluation code by adding the 59 modifier to 97140 manual therapy.
When you look at the eval codes – 97165 for OT -it appears you can bill with 97530. But not the other way around. Why is that? Didn’t the columns “go away” last year which allowed modifier on either code?
With NCCI Edits Version 26.0, the evaluation CPT codes are considered a component of the more comprehensive CPT code 97530. For Medicare, you can append modifier 59 to either the Column 1 or Column 2 CPT code.
Hi Rick, Please confirm that this new NCCI edit applies to private practice PT. Previously to get insurance to pay we have applied 59 modifier to 97530 GP, when billing 97140 GP and 97530 GP on the same day – to avoid the mutually exclusive clause to prevail.
Has this now flipped in that we should append the 59 modifier only to the 97140 GP cpt code when billing with 97530 GP?
So now, can we append 59 modifier for both CPT codes 97140 GP and 97530 GP when treatment provided alone or with an evaluation or re-evaluation?
Fran Levine
Pjysiofitness PT PC
email: Fran@Physiofitness.com
NCCI edits apply to all outpatient therapy settings.
Is it correct that a PT or OT Eval will not be paid on the same date if 97530 is performed regardless of whether you use the 59 modifier?
Please look at the NCCI Reference Sheet on my website for your answer as well as read this article: https://gawendaseminars.com/significant-changes-to-ncci-edits-effective-january-1-2020/
I assume, with all CCIs, they are not discipline-specific. Ex: If PT bills an eval code on 1/1/20, OT cannot bill 97530 on 1/1/20, even when the GO and GP modifiers are assigned?
You are correct!
Hi Rick,
As always, I find these NCCI edits extremely helpful with billing.
To just clarify, Medicare programs will not pay for PT or OT evaluations if 97530 is billed on the same date of service. Also, when billing an OT evaluation with manual therapy the 59 modifier will need to be added to 97140 for all complexities of evaluations.
Have any other insurance companies adopted this same restriction? Specifically ASH/Cigna?
You will need to check with them. If they follow the CMS NCCI edits every quarter, it’s a good chance they will be following Version 26.0 efective January 1 – March 31, 2020.
Do you put the 59 modifier on the cpt code that is in column one or on the cpt code in column two? It looks like you now have to put the 59 modifier on 97140 instead of 97530 when billing those codes together. Is that correct?
Thank you!
For your answer, please read this article: https://gawendaseminars.com/application-of-modifier-59-changing-on-july-1st/
Since Medicare will not allow billing of 97530 with an initial evaluation, if you are educating a patient on their HEP, goals, POCs, posture, etc. Would you recommend billing for services under 97535?
Thank you
Shannon
You would bill the CPT code that best describes what you are teaching and/or educating the patient in.
In the template letter attached to the announcement on the APTA it also says that 97530 and 97140 can not be billed together? Is this correct. From reading your article it looks as though this combination is still ok to be billed together, just as long as it is not billed with eval codes 97161, 97162, and 97163?
Please refer to the latest edition of the NCCI edits for your answer. I have provided the reference sheet on my website.
If these codes are performed and billed together in error, would we apply a GZ modifier to alert Medicare that we do not expect payment for the eval code?
No.
Hi Rick, does this have any impact on Speech therapy billing 97150 on the dame day as at PT/OT evaluation?
Yes if billed under the same NPI number.
With the biofeedback codes, must you still do 4 weeks of traditional pelvic floor muscle retraining before having biofeedback covered?
The requirements to use biofeedback for pelvic health did not change with the new CPT codes.
For the new cognitive codes in 2020: 97129 and 97130 can these be billed with 92507? It is unclear when reading your NCCI edits tip sheet compared to the CMS Chap 11 NCCI policy manual. Thanks!
It is not a NCCI edit but you have to follow the instructions in the NCCI policy manual.
Hi Rick, I noticed the new edits are for the first quarter (through March 31, 2020). Do you know yet if this changes again as of April 1st? If not, when do you anticipate knowing/sharing?
NCCI edits are updated quarterly on January 1st, April 1st, July 1st, and October 1st of every year.
is anyone still having trouble getting paid when billing a PT eval with the 97140-59.
What insurance carrier are you asking about?
For CPT Speech therapy, can we bill the 92507 with the 97530 and 97535 as long as we use the 59 modifier? We are constantly getting denials for the 97535 and/or 97530 for “improper modifier, cannot bill column 1 code with a column 2 code”. This is only for Anthem that we are always fighting.
If you are asking if a SLP can bill 97530 and 97535 on same day as 92507, my answer is most likely no. Most insurance carriers do not pay SLPs for the 97000 series CPT codes.
Do you have any insight on billing the 97129 and the 97130 together for speech therapy? We can not seem to get paid for this. I am not sure what we are missing or leaving off of these particular claims.
It’s difficult for me to answer as I would need to look at your claim forms as well as the EOB’s to see why you are not being paid. This would fall under my consulting services. If interested in a contract proposal for consultation services, please email me the name and address of your organization and the name and title of the person who would sign the contract and I will email you a contract proposal.
Rick – What is your recommendation on the use of the x-subset modifiers as opposed to the standard 59 modifier in a setting that sees multi-disciplinary PT, OT, and ST. Thanks.
Why use the x-subset modifiers if they are not mandated by the insurance carrier yet?
Are supplies (i.e. internal or external probes) part of the practice expense for CPT 90912 and 90913?
Yes