Therapy Evaluations Not Paid in Emergency Department

October 22, 2020
Rick Gawenda

Over the past 2 weeks, I have been receiving emails from hospital therapy directors and billing departments stating they are no longer being paid for a physical therapy or occupational therapy evaluation or reevaluation when performed on a Medicare beneficiary who presents to their emergency department. In this article, I will explain why this is occurring.

Effective with dates of service on and after

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  1. I understand that evals will no longer be paid but will the treatments (gait training for example) be paid when billed the same day as the emergency department codes?

    1. You would want to look at the full list of the NCCI PTP edits. Simple answer, treatment codes will be paid on same date of service that the applicable physician codes discussed in this article are also billed.

  2. Rick, thank you for the update. I think Russell is asking more Why would Medicare not feel that a PT or OT evaluation would be important and billable during an ER visit. I am sure many of us are in the same situation where patients come to the ED and need our services to safely discharge them back to the community setting directly from the ED. Is CMS recommending that we proceed differently to assure the safety of our patients or there is no consideration for these circumstances, just a decision without understanding the full impact? Is this being challenged by our professional associations? We are obviously going to be stuck with this for the quarter, but are we reaching out as a group to get it reversed?

    1. The PTP edit rationale is “standard of medical/surgical practice”. I can’t make this stuff up! 🙂

    2. Perfect response, Tracilyn. I think more awareness and further inquiry would be useful because as Rick identified, they were not explanatory in their rationale. If we, within the association, do not say/do anything, who will?

  3. Have we found any way to manage through this? We are working on shortening our length of stay in the hospitals and are trying to get to patients as soon as possible – we are excited when we see them on the same day as admitted through the ED. Does reimbursement for the eval change if pt ends up being admitted, or in observation status or is discharged from the ED – I am guessing the answer is no, but I just want to check.

    1. If they are admitted and qualify for an inpatient stay, you are paid via DRG’s and not by CPT code. Observation status would be considered outpatient.

  4. I received this when I sent my concerns to Capitalbridge, 10/22/2020
    Dear Strimbeck,
    Thank you for your inquiry regarding the National Correct Coding Initiative (NCCI) program. The Centers for Medicare & Medicaid Services (CMS) owns the NCCI program and is responsible for all decisions regarding its contents.
    In your correspondence, you inquired about particular Procedure-to-Procedure (PTP) edits regarding ED E/M codes with PT and OT evaluation codes.
    CMS evaluated your request and decided to make changes to the NCCI Procedure-to-Procedure (PTP) edits. The change will be implemented in a future edit update. The update will be available for Medicare and Medicaid on the CMS website.

    CMS recommends that if you have further questions about how to bill these code pairs, that you contact your national healthcare organization or the National Healthcare Organization (NHO) whose members commonly perform the procedures.

    CMS and the NCCI Program appreciate your time in making this inquiry.


    Capitol Bridge, LLC
    National Correct Coding Initiative Contractor
    P.O. Box 368
    Pittsboro, IN 46167
    SBA Certified 8(a) Small Disadvantaged Business

    1. Katesel- do you interpret this to mean they may change the edits in future releases, so that this is no longer an issue? Rick have you received any information about them reversing this? what a horrible edit!

      1. We have to wait for an update from CMS either during this quarter or will they wait and do the update with Version 27.0 that becomes effective January 1, 2021. If the latter, will they retro the effective date back to prior to October 1, 2020? All unknowns at this time.

    2. Great job reaching out. Although their response is still largely undetermined, that is much better than a negative response or a firm stance against the change.

  5. Hi Rick,

    Thanks for the update. Would this also apply to speech therapy services provided in the ED? Just to make sure that I am clear, non-payment of the therapy eval will only occur if the patient does not go into observation or inpatient status?



    1. You would want to look at the current version of the NCCI edits for your answer since there are so many different combinations.

  6. We do several ED evaluations for vertigo (Vestibular), in case they are no admitted or are not OBS status is there any other way we can bill for it and get paid? These patients need ot be seen while in the ED. Of course these are CMS regulations but is there a way around so these patients who need care get seen timely?
    Just wondering 🙂
    Thanks as always for the update.

    1. Perfect case to try to involve patients in a campaign to sway CMS back towards allowing the pair.

  7. Does anyone know if CMS will retro pay for evaluations performed in the EC during the 3rd quarter of 2020?

    1. Since the deletion date of this PTP edit goes back to January 1, 2020, my opinion would be to resubmit the claim in January 2021 and hopefully your MAC has updated their software.