Thursday, December 29, 2016

AHCA Member Advocacy Helps Prevent Improper Outpatient Therapy Payment Edits in 2017

Dan Ciolek
AHCA Associate Vice President of Therapy Advocacy

In early December, the Centers for Medicare and Medicaid Services (CMS) released the quarterly National Correct Coding Initiative (NCCI) edits tables that apply to Medicare Part B and some state Medicaid agency claims for the period of January 1 through March 31, 2017. NCCI edits look at combinations of procedure codes submitted on claims, and denies payment for codes that should not be billed together on the same day. Some codes listed in the edits can be billed together in certain situations, but only if an appropriate modifier (e.g. -59) is appended to the procedure code that would ordinarily be denied by the edit.

However, AHCA members noticed that there appeared to be errors in the edits that will apply to the new physical therapy (PT) and occupational therapy (OT) evaluation code combinations 97162/97165, 97163/97165, and 97165/97164. In the posted NCCI edits tables, these PT and OT code combinations could never be billed on the same day, even with an appropriate modifier. This appeared to be inconsistent with CMS policy that has always permitted PT and OT evaluations on the same day if medically necessary, and AHCA submitted a request to CMS to review the published NCCI edits tables, and provide corrections as appropriate. In a follow-up communication with CMS, AHCA also cited concerns that the incorrect edits could potentially have a negative downstream impact on the outpatient therapy claims-based functional reporting requirement if not corrected by January 1, 2017.

CMS responded favorably regarding the concerns raised by AHCA in two letters dated December 13 and December 28, 2016. Specifically, CMS has issued a technical direction letter (TDL) to the Medicare Administrative Contractors (MACs) to utilize a workaround from January 1 through March 31, 2017 to bypass the incorrect procedure-to-procedure (PTP) edits for the Current Procedural Terminology (CPT) PT and OT evaluation code combinations 97162/97165, 97163/97165, and 97165/97164, until they can be correctly updated in the April 1, 2017 version of the NCCI edits tables. CMS also provided instructions to the state Medicaid agencies that apply NCCI edits to outpatient therapy CPT codes.

After reviewing the letters, AHCA believes that these actions by CMS should adequately address the concerns we raised, and providers should use the appropriate new PT and OT evaluation codes as defined without fear of improper NCCI edit denials. Outpatient therapy providers should not receive NCCI edit denials for these three code combinations beginning January 1, as long as the appropriate modifier (e.g. 59) is appended to the claim. Please inform AHCA’s Associate Vice President of Therapy Advocacy Dan Ciolek at dciolek@ahca.org immediately if you receive any such denials, and we will inform CMS so they may resolve the issue ASAP.

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