Tuesday, December 13, 2016

CMS Updates Claims Processing for New Part B PT & OT Evaluation Codes in 2017


On December 8, the Centers of Medicare and Medicaid Services (CMS) released a MLN Matters Article MM 9698 titled Update to Editing of Therapy Services to Reflect Coding Changes. If you recall, as part of the calendar year (CY) 2017 Medicare Physician Fees Schedule (MPFS) final rule, CMS is retiring four physical therapy (PT) and occupational therapy (OT) evaluation codes (97001-97004) at the end of 2016, and replacing them with eight new codes (97161-97168) that are to be submitted for Part B therapy services (see here).     


This new article from CMS contains guidance to assist Part B therapy providers in properly submitting Part B therapy claims with the new PT and OT evaluation codes, beginning January 1, 2017, so that the claims are not Returned to Provider (RTP) as unprocessable. Specifically, the instructions describe how CMS is changing its claims processing policies and system edits to permit the new PT and OT evaluation codes to be aligned with existing policies that: 1) require therapy evaluation codes to be submitted with an associated discipline-specific modifier (GP for PT services and GO for OT services), and 2) require functional reporting G-codes and severity modifiers to be submitted when an evaluative service is furnished and billed.   


SNF therapy and billing staff are encouraged to review this document and the associated CMS Transmittal CR 9698. Compliance with the new coding requirements in 2017 is necessary or, as the article describes, the MAC will not process the claim and will Return to Provider (RTP) for correction. 


Please contact AHCA’s Associate Vice President, Therapy Advocacy at dciolek@ahca.org if there are questions.

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