Update on Evaluation and Therapeutic Activities Same Day

January 24, 2020
Rick Gawenda

Breaking news from the Centers for Medicare and Medicaid Services (CMS) regarding the payment of a physical therapy evaluation and/or occupational therapy evaluation on the same day you bill therapeutic activities.

Several professional organizations have received notice from Capital Bridge, LLC, National Correct Coding Initiative Contractor, announcing they will

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What About Group Therapy and an Evaluation on the Same Day?

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What About Manual Therapy and an Evaluation Same Day?

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  1. does this impact Medicare? it didn’t say specifically so want to clarify it is not required for Medicare patients per this update

  2. Has anyone else had problems with non-Medicare payers (i.e. Humana and Aetna replacement plans)? We have attached the -59 modifier to the 97140 code on same day that billing evaluation and these insurances are still not covering the 97140 code.

    1. This has been going on for about 2 years. They say they follow the CMS NCCI edits, but when we use Modifier 59 as appropriate, they are still denying the Column 2 CPT code and even upon appeal, are not paying.

      1. Is there anything we can do about this? Contact the insurance company? Any other resources you would advise us to use to work towards reimbursement of 97140 when also billing for initial evaluation?

    2. Humana is always a nightmare and will not pay with a modifier 59 on anything and like you they will not pay even with appeals. I have waisted countless hours fighting with them and I get the same answers, them just reading from a script. Aetna with us is capitated so no matter what we bill we get the same amount.

  3. Good afternoon Rick.

    Any word on when we can start billing for these together again? Also, will it we be able to go back to the start of the year to bill these properly?

    1. CMS has updated the NCCI edit file, but has not released any instructions yet. It will go retro-active to January 1, 2020.

  4. Rick, would you recommend waiting on the instructions from CMS PRIOR to billing THA and eval again?

    or should we proceed assuming retro- payment?

  5. I just had one of my medicare claims with eval denied and it was billed with TA. I have also had commercial insurances do the same thing. Mostly bcbs and Meritain. Do we just wait or do we need to appeal? Thanks

      1. none of my medicare evals have been paid with 97530. The one I am looking at right now was billed 02/26/2020. It was denied and I went into the FISS system and rekeyed it and it was denied again. Another one I am lookiing at was billed 03/02/2020 and it was also rekeyed in the FISS system and denied again.

        1. one billed 03/09/2020 denied and I have not rekeyed it as of yet because I just got it back EFT has a pay date as today.

  6. Hi Rick,

    Is this edit applicable to Therapeutic exercises, Neuromuscular Reeducation, Gait training .

  7. As of what date were we allowed to begin billing Therapeutic Activity and Eval on the same day agian?

  8. We are getting line items denials for OT and PT evaluations billed with 97530 in late February 2020 for both WPS and Novitas. The reason code is W2070 CODE 2 OF A CODE PAIR THAT WOULD BE ALLOWED BY NCCI IF APPROPRIATE MODIFIER WERE PRESENT.
    Based on the information above no modifier is required for code pair Eval/97530. The WPS representative was unfamiliar with the change of the NCCI edit. Anyone else encountered this? Resolution?

  9. we are still having problems with NC BCBS stating the PTP edit is still valid. Is there a reference we can use where Capital Bridge put in writing this edit was rescinded? thanks

      1. I have yet to get evaluations paid when billed together. I filed appeal with cms and put the website on the appeal and just received letters back on every patient that appeal was denied.
        Claim(s) or line(s) that reject with reason code(s) W7020 are not appealable. The reason code(s) indicate(s) that claim was submitted with a code 2 of a code pair that is not allowed by National Correct Coding Initiative (NCCI) even if the appropriate modifier is present. You may submit an adjustment(s) to your claim(s).

  10. anyone having any luck with getting your evals paid when billed with 97530? The ones that I have rekeyed into the DDE system and added the above website in remarks were denied again. I have now gone into the eservice on palmetto’s website and filed appeals on all the claims and again attached the above website. Hoping this will work… if anyone has had any luck can you advise on what you did to finally get them through.


  11. has anyone had luck with Novitas in calif. pay the 97530 and 97110 since the edit was lifted?

  12. Hi Rick,

    We are still getting rejected on claims with 97140 with 97530 + 59 modifier for Humana Advantage, Aetna and Aetna advantage since the Jan 2020 edits came out. This all started with the NCCI edit mistake of January 2020.

    Usually we get paid with a resubmit but now this is getting denied. Do you have any advice on how to handle this?

    Its like they have not changed the programming on their billing software so it kicks it out. Thanks.