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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medicare Updates

  • Updates to Reflect Removal of Functional Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018

    25 Jan 2019 2:53 PM | Zachary Edgar (Administrator)

    Effective Date: 2/26/2019

    This update is intended for therapists, physicians, certain nonphysician practitioners and other providers of therapy services – including physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services − who submit professional or institutional claims to Medicare Administrative Contractors (MACs) for therapy services provided to Medicare beneficiaries.

    CR 11120 updates both the Medicare Benefit Policy Manual and Medicare Claims Processing Manual to reflect recent changes in outpatient therapy services billing instructions and payment policies related to the Bipartisan Budget Act of 2018 and the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule. These policy revisions include:

    • The repeal of the application of the outpatient therapy caps and the retention of the therapy cap amounts as thresholds of incurred expenses above which claims must include a modifier to confirm services are medically necessary as shown by medical record documentation; and,
    • The discontinuation of the functional reporting requirements.

    Background

    Section 50202 of the Bipartisan Budget Act of 2018 (BBA of 2018) repeals application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold of incurred expenses above which claims must include a KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.

    After a consideration of stakeholders’ requests for burden reduction and a review of the Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA) requirements, the Centers for Medicare & Medicaid Services (CMS) concluded in the CY 2019 MPFS final rule that continued collection of functional reporting data through the same format would not yield additional information to inform future analyses. The rule ended the functional reporting requirements to reduce burden of reporting for providers of therapy services.

    CR 11120 updates Chapters 12 and 15 of the Medicare Benefit Policy Manual and Chapter 5 of the Medicare Claims Policy Manual to reflect these changes to law and regulation. Note: The relevant manual chapters are attached to CR 11120 for your review.

    Effective for dates of service on or after January 1, 2018, providers of therapy services shall continue to report the KX modifier on claims as applicable. The modifier no longer represents an exception request but serves as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record after the beneficiary has exceeded the threshold of incurred expenses.

    Effective for dates of service on or after January 1, 2019, HCPCS G-codes and severity modifiers for functional reporting are no longer required on claims for therapy services.

    Reference

    MLN Matters MM11120

  • Reporting Requirements and Therapy Provisions of the Bipartisan Budget Act of 2018

    25 Jan 2019 1:38 PM | Zachary Edgar (Administrator)

    Effective Date: January 1, 2019

    Applicable Providers

    Therapists, physicians, certain non-physician practitioners and other providers of therapy services – including physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) services − who submit professional or institutional claims to Medicare Administrative Contractors (MACs) for therapy services provided to Medicare beneficiaries

    Compliance Change

    CR 11120 updates both the Medicare Benefit Policy Manual and Medicare Claims Processing Manual to reflect recent changes in outpatient therapy services billing instructions and payment policies related to the Bipartisan Budget Act of 2018 and the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule.

    These policy revisions include:

    • The repeal of the application of the outpatient therapy caps and the retention of the therapy cap amounts as thresholds of incurred expenses above which claims must include a modifier to confirm services are medically necessary as shown by medical record documentation; and,
    • The discontinuation of the functional reporting requirements. Please make sure your billing staffs are aware of these changes.

    Effective for dates of service on or after January 1, 2018, providers of therapy services shall continue to report the KX modifier on claims as applicable. The modifier no longer represents an exception request but serves as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record after the beneficiary has exceeded the threshold of incurred expenses. Effective for dates of service on or after January 1, 2019, HCPCS G-codes and severity modifiers for functional reporting are no longer required on claims for therapy services.

    Background Information

    Section 50202 of the Bipartisan Budget Act of 2018 (BBA of 2018) repeals application of the Medicare outpatient therapy caps but retains the former cap amounts as a threshold of incurred expenses above which claims must include a KX modifier as a confirmation that services are medically necessary as justified by appropriate documentation in the medical record.

    After a consideration of stakeholders’ requests for burden reduction and a review of the Middle Class Tax Relief and Jobs Creation Act of 2012 (MCTRJCA) requirements, the Centers for Medicare & Medicaid Services (CMS) concluded in the CY 2019 MPFS final rule that continued collection of functional reporting data through the same format would not yield additional information to inform future analyses. The rule ended the functional reporting requirements to reduce burden of reporting for providers of therapy services.


  • Annual Update to the Per-Beneficiary Therapy Amounts

    30 Nov 2018 12:12 PM | Zachary Edgar (Administrator)

    Effective Date: 1/7/2019

    This update is intended for physicians, therapists, and other providers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.

    CR 11055 describes the annual per-beneficiary incurred expense amounts now known as the KX modifier thresholds, and related policy updates for CY 2019. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed when the Bipartisan Budget Act of 2018 (BBA of 2018) was signed into law. Another provision of the BBA of 2018 lowers the threshold of the targeted medical review process as explained in the Background section below.

    For CY 2019, the KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined is $2,040. For occupational therapy (OT) services, the CY 2019 threshold amount is $2,040. Make sure that your billing staffs are aware of these updates.

    Background

    Effective for January 1, 2018, section 50202 of the Bipartisan Budget Act of 2018, P.L. 115-123 (BBA of 2018) amended section 1833(g) of the Social Security Act (the Act) to repeal the application of the therapy caps and the therapy caps exceptions process while also retaining and adding limitations to ensure appropriate therapy. The therapy caps or financial limitations originally applied through section 4541(c) of the Balanced Budget Act of 1997, P.L. 105-33 (1997 BBA) are no longer applicable to beneficiaries.

    A separate provision of section 50202 of the BBA of 2018 adds section 1833(g)(7)(A) of the Act to preserve the former therapy cap amounts as thresholds above which claims must include the KX modifier to confirm that services are medically necessary as justified by appropriate documentation in the medical record. Claims from suppliers or providers for therapy services above these amounts without the KX modifier are denied. These amounts are now known as the KX modifier thresholds.

    Just as with the incurred expenses for the therapy cap amounts, there is one KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined and a separate amount for occupational therapy (OT) services. These perbeneficiary amounts under section 1833(g) of the Act (as amended by 1997 BBA) are updated each year by the Medicare Economic Index (MEI).

    For CY 2019, the KX modifier threshold amounts are: (a) $2,040 for PT and SLP services combined, and (b) $2,040 for OT services.

    Another provision of section 50202 of the BBA of 2018 adds section 1833(g)(7)(B) of the Act which maintains the targeted medical review process (first established through section 202 of the Medicare Access and CHIP Reauthorization Act of 2015), but at a lower threshold than the $3,700 amount established as part of the therapy caps exceptions process via section 3005 of the Middle Class Tax Relief and Jobs Creation Act of 2012. For CY 2018 (and each successive calendar year until 2028, at which time it is indexed annually by the MEI), this now-termed Medical Review (MR) threshold amount is $3,000 for PT and SLP services combined and $3,000 for OT services.

    Reference

    MLN Matters Number: MM11055


  • 2019 Update to the Per-Beneficiary Therapy Amounts

    30 Nov 2018 10:57 AM | Zachary Edgar (Administrator)

    Effective Date: January 1, 2019

    Applicable Providers

    Physicians, therapists, and other providers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.

    Compliance Change

    For CY 2019, the KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined is $2,040. For occupational therapy (OT) services, the CY 2019 threshold amount is $2,040.

    The annual per-beneficiary incurred expense amounts now known as the KX modifier thresholds, and related policy updates for CY 2019. These amounts were previously associated with the financial limitation amounts that were more commonly referred to as “therapy caps” before the application of the therapy limits/caps was repealed when the Bipartisan Budget Act of 2018 (BBA of 2018) was signed into law.

    Reference

    MLN Matters Number: MM11055


  • Modifications Within Common Working File (CWF) to Adjustment Claims Exceeding Annual Therapy Threshold

    10 Aug 2018 12:10 PM | Zachary Edgar (Administrator)

    Effective Date: 1/7/2019

    The purpose of this Change Request (CR) is for CWF to modify the process to set CWF edits correctly on adjustment claims when the therapy threshold is exceeded.

    Background: Currently, when CWF receives an adjustment to a therapy (physical-PT, speech-SP, or occupational-OT) claim which had been paid prior to the therapy cap being reached, CWF searches to see if the beneficiary exceeded the threshold. If the beneficiary exceeds the threshold then CWF subjects the adjustment claim(s) to the normal therapy threshold processing, and if no 'KX' modifier is present, rejects the adjustment claim(s) and generates an edit which ultimately results in the original claim being treated as an overpayment.

    The CMS request CWF to review CR 8938 and ensure that the system is in compliance with the therapy adjustment requirements and modify/revise the software if when necessary.

    The contractor shall ensure that the adjustments to therapy claims for PT/SP and/or OT service(s) are excluded from therapy edits and threshold limits

    Reference

    Transmittal # R2111OTN


  • Clarification of Instructions Regarding the Intensive Level of Rehabilitation Therapy Services Requirements

    23 Feb 2018 11:59 AM | Zachary Edgar (Administrator)

    Effective Date: 3/23/2018

    The purpose of this Change Request (CR) is to clarify the instructions for conducting medical review of Inpatient Rehabilitation Facility (IRF) claims when reviewing the requirements for the intensive level of rehabilitation therapy services.

    Contractors shall verify that the IRF documentation requirements are met in accordance with Pub 100-02, Medicare Benefit Policy Manual, Chapter 1, Section 110.

    Contractors shall not make denials based solely on any threshold of therapy time.

    Contractors shall use clinical review judgment to determine medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of the case.

    Contractors shall not make denials solely because the situation/rationale that justifies group therapy is not specified in the patient’s medical records at the IRF.

    Reference

    Transmittal #R771PI

  • 2018 Annual Update to the Therapy Code List

    16 Nov 2017 11:40 AM | Zachary Edgar (Administrator)

    Effective Date: 1/2/2018

    This update is intended for physicians, therapists, and other providers, including Comprehensive Outpatient Rehabilitation Facilities (CORFs), submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.

    Change Request (CR) 10303 updates the list of codes that sometimes or always describe therapy services and their associated policies. The additions, changes, and deletions to the therapy code list reflect those made in the Calendar Year (CY) 2018 Healthcare Common Procedure Coding System and Current Procedural Terminology, Fourth Edition (HCPCS/CPT4). The therapy code listing is available at http://www.cms.gov/Medicare/Billing/TherapyServices/index.html

    Background

    The Social Security Act (Section 1834(k)(5)) requires that all claims for outpatient rehabilitation therapy services and all Comprehensive Outpatient Rehabilitation Facility (CORF) services be reported using a uniform coding system. The Calendar Year (CY) 2018 Healthcare Common Procedure Coding System and Current Procedural Terminology, Fourth Edition (HCPCS/CPT-4) is the coding system used for the reporting of these services.

    The policies implemented in CR10303 were discussed in CY 2018 Medicare Physician Fee Schedule (MPFS) rulemaking. CR10303 updates the therapy code list and associated policies for CY 2018, as follows:

    The Current Procedural Terminology (CPT) Editorial Panel revised the set of codes physical and occupational therapists use to report orthotic and prosthetic management and training services by differentiating between initial and subsequent encounters through the: (a) addition of the term “initial encounter” to the code descriptors for CPT codes 97760 and 97761, (b) creation of CPT code 97763 to describe all subsequent encounters for orthotics and/or prosthetics management and training services, and (c) deletion of CPT code 97762. The new long descriptors for CPT codes 97760 and 97761 – now intended only to be reported for the initial encounter with the patient – are:

    • CPT code 97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes)
    • CPT code 97761 (Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes)

    The Centers for Medicare & Medicaid Services (CMS) will add CPT code 97763 to the therapy code list and CPT code 97762 will be deleted.

    The panel also created, for CY 2018, CPT code 97127 to replace/delete CPT code 97532. CMS will recognize HCPCS code G0515, instead of CPT code 97127, and add HCPCS code G0515 to the therapy code list. CPT code 97127 will be assigned a Medicare Physician Fee Schedule (MPFS) payment status indicator of “I” to indicate that it is “invalid” for Medicare purposes and that another code is used for reporting and payment for these services.

    Just as its predecessor code was, CPT code 97763 is designated as “always therapy” and must always be reported with the appropriate therapy modifier, GN, GO or GP, to indicate whether it’s under a Speech-language pathology (SLP), Occupational Therapy (OT) or Physical Therapy (PT) plan of care, respectively.

     HCPCS code G0515 is designated as a “sometimes therapy” code, which means that an appropriate therapy modifier − GN, GO or GP, to reflect it’s under an SLP, OT, or PT plan of care – is always required when this service is furnished by therapists; and, when it’s furnished by or incident to physicians and certain Nonphysician Practitioners (NPPs), that is, nurse practitioners, physician assistants, and clinical nurse specialists when the services are integral to an SLP, OT, or PT plan of care. Accordingly, HCPCS code G0515 is sometimes appropriately reported by physicians, NPPs, and psychologists without a therapy modifier when it is appropriately furnished outside an SLP, OT, or PT plan of care. When furnished by psychologists, the services of HCPCS code G0515 are never considered therapy services and may not be reported with a GN, GO, or GP therapy modifier.

    The therapy code list is updated with one new “always therapy” code and one new “sometimes therapy” code, using their HCPCS/CPT long descriptors, as follows:

    • CPT code 97763 – This “always therapy” code replaces/deletes CPT code 97762. o CPT code 97763: Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes
    • HCPCS code G0515 – This “sometimes therapy” code replaces/deletes CPT code 97532.
    • HCPCS code G0515: Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

    Reference

    MLN Matters MM10303


  • Therapy Cap Values for Calendar Year (CY) 2018

    9 Nov 2017 11:39 AM | Zachary Edgar (Administrator)

    Effective Date: 1/2/2018

    Change Request (CR) 10341 provides the amounts for outpatient therapy caps for Calendar Year (CY) 2018. For physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010. For occupational therapy, the CY 2018 cap is $2,010. Make sure that your billing staffs are aware of these therapy cap value updates.

    Background

    The Balanced Budget Act of 1997, P.L. 105-33, Section 4541(c) applies, per beneficiary, annual financial limitations on expenses considered incurred for outpatient therapy services under Medicare Part B, commonly referred to as “therapy caps.” The therapy caps are updated each year based on the Medicare Economic Index.

    Section 5107 of the Deficit Reduction Act of 2005 required an exceptions process to the therapy caps for reasonable and medically necessary services. The exceptions process for the therapy caps has been continuously extended several times through subsequent legislation. Most recently, Section 202 of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) extended the therapy caps exceptions process through December 31, 2017.

    Reference

    MLN Matters MM10341


  • 2018 Update to the Per-Beneficiary Therapy Amounts

    9 Nov 2017 10:56 AM | Zachary Edgar (Administrator)

    Effective Date: January 1, 2018

    Applicable Providers

    Therapists, physicians, and other providers submitting claims to Medicare Administrative Contractors (MACs), including Home Health & Hospice MACs, for outpatient therapy services provided to Medicare beneficiaries.

    Compliance Change

    For physical therapy and speech-language pathology combined, the CY 2018 cap is $2,010. For occupational therapy, the CY 2018 cap is $2,010. Make sure that your billing staffs are aware of these therapy cap value updates.

    Reference

    MLN Matters Number: MM10341

  • Updated Editing of Always Therapy Services – MCS

    27 Jul 2017 11:34 AM | Zachary Edgar (Administrator)

    Effective Date: 1/2/2018

    CR 10176 implements revised editing of Part B “Always Therapy” services to require the appropriate therapy modifier in order for the service to be accurately applied to the therapy cap. CR10176 contains no new policy. Instead, the guidelines presented in the CR improve the enforcement of longstanding, existing instructions. Make sure your billing staffs are aware of these revisions.

    Services furnished under the Outpatient Therapy (OPT) services benefit – including Speech Language Pathology (SLP), Occupational Therapy (OT), and Physical Therapy (PT) – are subject to the financial limitations, known as therapy caps, originally required under Section 4541 of the Balanced Budget Act (1997).

    There are two such caps. One cap is for PT and SLP services combined and another cap is for OT services. In order to accrue incurred expenses to the correct therapy cap; the use of one of the three therapy modifiers (GN, GO, or GP) is required on a certain set of Healthcare Common Procedure Coding System (HCPCS) codes in order to identify when each OPT service is furnished under an SLP, OT, or PT plan of care, respectively.

    Medicare recognizes the services furnished under the OPT services benefit as either “always” or “sometimes” therapy and publishes this list as an Annual Update on the Therapy Services Billing page at https://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html.

    On professional claims, each code designated as “always therapy”:

    • Must always be furnished under an SLP, OT, or PT plan of care, regardless of who furnishes them; and, as such,
    • Must always be accompanied by one of the GN, GO, or GP therapy modifiers.

    In addition, several “always therapy” codes have been identified as discipline-specific – requiring the GN modifier for six codes, the GO modifier for four codes, and the GP modifier for four codes, as illustrated in Tables 1-3.

    Table 1: Codes Requiring the “GN” Therapy Modifier

    Code

    Description

    Modifier

    92521

    Evaluation of speech fluency

    GN

    92522

    Evaluate speech production

    GN

    92523

    Speech sound lang comprehend

    GN

    92524

    Behavral quality analys voice

    GN

    92597

    Oral speech device eval

    GN

    92607

    Ex for speech device rx 1hr

    GN

    Table 2: Codes Requiring the “GO” Therapy Modifier

    Code

    Description

    Modifier

    97165

    Ot eval low complex 30 min

    GO

    97166

    Ot eval mod complex 45 min

    GO

    97167

    Ot eval high complex 60 min

    GO

    97168

    Ot re-eval est plan care

    GO

    Table 3: Codes Requiring the “GP” Therapy Modifier

    Code

    Description

    Modifier

    97161

    Pt eval low complex 20 min

    GP

    97162

    Pt eval mod complex 30 min

    GP

    97163

    Pt eval high complex 45 min

    GP

    97164

    Pt re-eval est plan care

    GP

    The following “Always Therapy” HCPCS codes require a GN, GO, or GP modifier, as appropriate. Descriptors for these codes are included as an attachment to CR 10176.

    92507 92508 92526 92608 92609 96125 97012 97016 97018 97022 97024 97026 97028 97032 97033 97034 97035 97036 97039 97110 97112 97113 97116 97124 97139 97140 97150 97530 97533 97535 97537 97542 97750 97755 97760 97761 97762 97799 G0281 G0283 G0329

    In addition to Therapists in Private Practice (TPPs) – including physical therapists, occupational therapists, and speech-language pathologists – professional claims for OPT services may be furnished by physicians and certain Non-Physician Practitioners (NPPs) – specifically, physician assistants, nurse practitioners, and certified nurse specialists.

    All OPT services furnished by TPPs are always considered therapy services, regardless of whether they are designated as “always therapy” or “sometimes therapy.” As such, the appropriate therapy modifier must be included on the claim. However, it may be clinically appropriate for physicians and NPPs to furnish OPT services that have been designated “sometimes therapy” codes outside a therapy plan of care - in these cases, therapy modifiers are not required and claims may be processed without them.

    During analyses of Medicare claims data for OPT services, the Centers for Medicare & Medicaid Services (CMS) found that these “always therapy” codes and modifiers are not always used in a correct and consistent manner. CMS found OPT professional claims for “always therapy” codes without the required modifiers. Also, CMS found claims that reported more than one therapy modifier for the same therapy service; for example, both a GP and GO modifier, when only one modifier was allowed.

    These claims represent non-compliant billing by TPPs, physicians, and NPPs, and hamper CMS’ ability to properly track the therapy caps and analyze claims data for purposes of Medicare program improvements. The requirements in CR10176 will create new edits for Medicare professional claims processing systems to return claims when “always therapy” codes and the associated therapy modifiers are improperly reported.

    Providers should expect the following:

    • MACs will return/reject claims which contain an “always therapy” procedure code, but do not also contain the appropriate discipline-specific therapy modifier of GN, GO, or GP.
    • MACs will also return/reject claims if any service line on the claim contains more than one occurrence of a GN, GO, or GP therapy modifier.
    • MACs who are returning/rejecting such claims will use Group Code CO and Claim Adjustment Reason Code (CARC) 4 on the related remittance advice.

    Reference

    MLN Matters MM10176

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