Gawenda Seminars
Seminars and Consulting
Join us for our webinar “The Path to More Completed Plans of Care: Can It Be as Simple as Your Front Desk?!” on August 26, 2020. This webinar will teach you how, by optimizing your Front Desk, you can improve your entire practice. Click HERE for further details and to register.
Question
For physical therapy services submitted to an insurance carrier on a 1500-claim form, how do I bill for the services provided by a physical therapist assistant?
Answer
This content is for Gold Members only. Please log in above or Register
I hope you found this article helpful. Thank you for being a Gold Member!
Question
For occupational therapy services submitted to an insurance carrier on a 1500-claim form, how do I bill for the services provided by an occupational therapy assistant?
Answer
This content is for Gold Members only. Please log in above or Register
I hope you found this article helpful. Thank you for being a Gold Member!
National Correct Coding Initiative (NCCI) edits are updated quarterly by the Centers for Medicare and Medicaid Services (CMS) and Capital Bridge, CMS’ NCCI coding contractor. Updates occur on January 1, April 1, July 1, and October 1 of each calendar year. Typically, the January 1 update sees the most additions, deletions and revisions due to new, revised and deleted CPT codes taking effect on January 1 of the calendar year.
Due to the COVID-19 Public Health Emergency as well as CMS’s expansion of telehealth services, CMS updated procedure-to-procedure (PTP) edits and Medically Unlikely Edits (MUEs) for Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes, retroactive to January 1, 2020. This announcement was posted on April 8, 2020 on the CMS website.
There have been many significant changes (well over 150) to the PTP edits applicable to physical, occupational and speech therapy services with all of them retroactive to January 1, 2020. Many of the NCCI edits have been deleted, including those that became effective January 1, 2020.
I have updated NCCI Version 26.0 for dates of service January 1, 2020 – March 31, 2020 for both the private practice setting and non-private practice settings. In addition, NCCI Version 26.1 for dates of service April 1, 2020 – June 30, 2020 has been published on my website for my Gold Members. To access the NCCI edit reference sheet, click HERE.
On March 30, 2020, the Centers for Medicare and Medicaid Services (CMS) issued an interim final rule titled “Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency“. In this interim final rule, CMS did add CPT codes that are typically billed by physical therapists (PTs), occupational therapists (OTs) and speech-language pathologists (SLPs) as covered telehealth services; however, they did not add PTs, OTs and SLPs as telehealth providers.
This led many to ask why would CMS add these CPT codes to the list of covered therapy services if they did not add PTs, OTs and SLPs as telehealth providers? This is because the Medicare program allows physicians, physician assistants, nurse practitioners, and clinical nurse specialists who is licensed or certified by the state to furnish therapy services can bill the CPT codes that were added to the list of covered telehealth services.
A second question that arose was can a physical therapist or occupational therapist who is employed by a physician practice perform a telehealth visit and have that visit billed incident-to a physician. Right now, we do not know the answer to this question and we are seeking clarification from CMS on this question.
Watch for updates if additional information becomes available. For those of you that are a Gold Member to my website, thank you! We appreciate your business and loyalty.
Due to the COVID-19 pandemic, many providers of outpatient therapy services are implementing telehealth services to meet the needs of their patients. Since many have never provided telehealth services previously, they are uncertain how to do the billing. In addition, insurance carriers who are expanding telehealth coverage, either voluntarily or state mandated, may not have guidance for providers regarding the billing of outpatient therapy telehealth services. In this article, I will provide answers and/or guidance on some of the questions I have been receiving.
Question
Does the Medicare program pay for telehealth services provided by a physical therapist, occupational therapist or speech-language pathologist for outpatient physical, occupational and speech therapy services?
Answer – Updated March 31, 2020
This content is for Gold Members only. Please log in above or Register
Question – Added March 31, 2020
Did the Centers for Medicare and Medicaid Services add any of the commonly billed CPT codes by physical therapists, occupational therapists and speech-language pathologists to the list of covered telehealth services?
Answer
This content is for Gold Members only. Please log in above or Register
Question – Added March 31, 2020
Who currently can bill the newly added CPT codes for telehealth services to the Medicare program?
Answer
This content is for Gold Members only. Please log in above or Register
Question
What CPT code(s) do I use when billing for outpatient therapy telehealth services?
Answer
This content is for Gold Members only. Please log in above or Register
Question
Can hospital outpatient therapy departments bill insurance carriers for telehealth services?
Answer
This content is for Gold Members only. Please log in above or Register
Question – Added April 1, 2020
For hospital outpatient therapy departments and getting paid for telehealth services, could it make a difference with an insurance carrier whether they submit claims on a 1500-claim form or a UB-04 claim form?
Answer
This content is for Gold Members only. Please log in above or Register
Question – Added April 1, 2020
For outpatient rehabilitation facilities (Rehabilitation Agency) and getting paid for telehealth services, could it make a difference with an insurance carrier whether they submit claims on a 1500-claim form or a UB-04 claim form?
Answer
This content is for Gold Members only. Please log in above or Register
Question
On the 1500-claim form, what place of service code do I use when providing telehealth services?
Answer
This content is for Gold Members only. Please log in above or Register
Question
On the UB-04-claim form, what place of service code do I use when providing telehealth services?
Answer
This content is for Gold Members only. Please log in above or Register
Question
Are there any other modifiers that we would need to use on the claim form if providing telehealth services?
Answer
This content is for Gold Members only. Please log in above or Register
Question
If telehealth is allowed by an insurance carrier, can a physical therapist assistant and occupational therapy assistant provide telehealth services?
Answer
This content is for Gold Members only. Please log in above or Register
Question
What is the difference between asynchronous and synchronous communication?
Answer
This content is for Gold Members only. Please log in above or Register
Question
I see many insurance carriers state they will pay for synchronous telehealth services for CPT codes list in Appendix P of the CPT book. What are the CPT codes listed in Appendix P?
Answer
This content is for Gold Members only. Please log in above or Register
I hope you found the questions and answers to be helpful. If you have additional questions, please email them to me and I will post the answers as applicable and appropriate. Keep in mind answers may change as CMS and other insurance carriers update their policies.
Thank you for being a Gold Member!
With many states mandating insurance plans in their state expand telehealth services and reimbursement to include physical therapy (PT), occupational therapy (OT) and speech therapy (ST) as well as several insurances expanding telehealth services and reimbursement on their own, I am being asked what CPT code(s) do I use to bill for telehealth services for physical, occupational and/or speech therapy services.
The answer is the one that you do not like. It is insurance carrier specific and you have to check with each insurance carrier and yes, this includes workers compensation. Codes that I am commonly seeing insurance companies mention are 97110, 97112, 97530 and 97535 for PT and OT and 92507 for ST.
I have also seen some insurance carriers list the 3 PT evaluation CPT codes (97161, 97162, 97163), the 3 OT evaluation CPT codes (97165, 97166, 97167) and 4 of the SLP evaluation CPT codes (92521, 92522, 92523, 92524).
The other thing you want to check with insurance carriers that are reimbursing for telehealth services for PT, OT and ST is in terms of is this only for current patients that were coming to the clinic or facility for therapy or can can telehealth be done for new patients and have the evaluations paid for by the insurance carrier. Also, is telehealth only reimbursable if you are an in-network provider or if you are out-of-network, will the insurance carrier pay the out-of-network benefit amount?
Lastly, many states have parity laws in place that require insurance carriers to pay for PT, OT and SLP at the same rate for telehealth services as they do if they patient came to your clinic or facility.
Reach out to us through our information below.
We look forward to hearing from you!
P: 734.531.7718 (Rick)
P: 661.350.6187 (Michelle)
F: 661.369.7199
Mr. Gawenda has presented nationally since 2004 and currently presents approximately 100 dates per year around the United States.
He has provided valuable education and consulting to hospitals, private practices, skilled nursing facilities, and rehabilitation agencies in the areas of CPT coding, ICD-10 coding, billing, documentation compliance, revenue enhancement, practice management, and denial management as they relate to outpatient therapy services.