Tuesday, January 2, 2018

CMS Updates Medicare Part B Therapy “Always Therapy” Code Edits List

Dan Ciolek

On December 21, 2017, the Center for Medicare and Medicaid Services (CMS) issued a transmittal update to delete the procedure code 97532 from the list of “Always Therapy” codes used to track the Medicare Part B therapy caps. The coding requirement change is effective for services furnished on or after January 1, 2018.  This is not new policy – only a change I the code list. SNF therapists and billers should be aware of this change. Additional details may be found in the CMS MLN Matters article released last week. 

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.  If providers do not follow the appropriate coding instructions for use of the GN, GO, or GP therapy modifiers, then the Medicare Administrative Contractor (MAC) will perform the following actions:

  • 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. 

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