Monday, August 14, 2017

CMS Posts Updated Part B Therapy Coding Scrutiny Starting January 2018

Dan Ciolek

Recently, the Centers of Medicare and Medicaid Services (CMS) posted a MLN Matters article (MM10176) titled “Updated Editing of Always Therapy Services -MCS.”  The article, intended for providers of Part B therapy services, identifies outpatient therapy procedures that must always be accompanied by a discipline-specific therapy modifier (GP = physical therapy, GO = occupational therapy, and GN = speech-language pathology services).

CMS also notes that per CR10176 instructions, they are requiring the Medicare Administrative Contractors (MACs) to update their claims-processing systems edits, as follows for services furnished on or after January 1, 2018:


  • 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.


The complete code list that this policy will apply to in CY 2018 will be posted later this year on the CMS Annual Therapy Update web page at https://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html.

In addition, while many of these codes can be used by any of the three therapy disciplines, CMS notes that 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 below.

AHCA recommends that SNF billers review this guidance.  If you have questions, contact Dan Ciolek, AHCA Associate Vice President, Therapy Advocacy.


Table 1: Codes Requiring the “GN” Therapy Modifier
Code
CPT Short Descriptor
Therapy Modifier Required
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 (NEW CODES for 2018)
Code
CPT Short Descriptor
Therapy Modifier Required
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 (NEW CODES for 2018)

Code
CPT Short Descriptor
Therapy Modifier Required
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

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