Significant Changes to NCCI Edits Version 23.2
The Centers for Medicare and Medicaid Services has released the quarterly update to the National Correct Coding Initiative (NCCI) edits for dates of service July 1 – September 30, 2017 and there are some significant changes this quarter that will impact physical therapists and occupational therapists performing an initial evaluation on the same date of service as well as additional updates for physical and occupational therapy regarding the reevaluation CPT codes. Lastly, I will discuss a new NCCI edit regarding Healthcare Common Procedure Coding System (HCPCS) Level II code G0505 and CPT codes 96105, 96110, 96111, 97161, 97162, 97163, 97164, 97165, 97166, 97167 and 97168.
Lets begin with the NCCI edit changes impacting a physical therapy and occupational therapy evaluation being performed and billed the same date of service on a Medicare beneficiary. These changes, effective for dates of service beginning July 1, 2017, will apply to all practice settings that includes private practice, skilled nursing facility doing Part B, rehabilitation agencies, comprehensive outpatient rehabilitation facility (CORF), home health doing Part B in the home, and hospital outpatient departments that could also include Medicare beneficiaries receiving a therapy evaluation in the emergency department, while under observation status, or have their inpatient stay switched from Part A to outpatient status (Part B) since they did not qualify for a hospital inpatient admission or had exhausted all of their Part A benefits.
If a Medicare beneficiary has a physical therapy evaluation and an occupational therapy evaluation on the same date of service at the same practice or organization, modifier 59 is{restrict paid=true] no longer required to be appended to the occupational therapy evaluation CPT code on the claim form. In addition, if an occupational therapy reevaluation (CPT code 97168) is billed on the same date of service as any one of the 3 physical therapy evaluation codes (CPT codes 97161 – 97163), modifier 59 is no longer required to be appended to the occupational therapy reevaluation CPT code on the claim form. Lastly, if a physical therapy reevaluation (CPT code 97164) is billed on the same date of service as any one of the 3 occupational therapy evaluation codes (CPT codes 97165 – 97167), modifier 59 is no longer required to be appended to the physical therapy reevaluation CPT code on the claim form.
HCPCS Level II code G0505 (Cognition and functional assessment using standardized instruments with development of recorded care plan for the patient with cognitive impairment, history obtained from patient and/or caregiver, by the physician or other qualified health care professional in office or other outpatient setting or home or domiciliary or rest home.) has been added as an NCCI edit when billed the same date of service as the following CPT codes: 96105, 96110, 96111, 97161, 97162, 97163, 97164, 97165, 97166, 97167 and 97168. Modifier 59 would need to be appended to G0505 on the claim form when billed the same date of service as any of the CPT codes listed above.
Any practitioner eligible to report evaluation and management (E/M) services can provide this service (G0505). Eligible providers include physicians (MD and DO), nurse practitioners, clinical nurse specialists, and physician assistants. As you see, an eligible professional does not include a physical therapist, occupational therapist or speech-language pathologist. Where this edit may be an issue is in a physician owned therapy practice where the physical therapist or occupational therapist is billing”incident-to” the physician. In this case, the physical therapy evaluation or occupational therapy evaluation is being billed under the physicians NPI number and the physician is also billing G0505 the same date of service. If this did occur, G0505 would require modifier 59 be appended to it on the claim form.
To access the Gawenda Seminars & Consulting NCCI “cheat sheet”, click HERE and then select the appropriate version based on your practice setting. I hope you enjoyed this article. Thanks for being a Gold Member![/mepr-show]
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Re the E/M service code G0505 in combo with the PT/OT eval—is this all insurances or only Medicare?
Thank you.
This would be for any insurance carrier who utilizes the NCCI edits. Whether an insurance carrier pays for G0505 or not wold be payer specific.