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Payment Committee

ACTION: CMS Coding Changes 10-19-20


As you may know, on October 1, the National Correct Coding Initiative procedure-to-procedure (PTP) edits associated with thousands of code pairs were reinstated after having been temporarily removed in early April. This includes the PTP edits for code pairs:

    •    99281-99285 (emergency department E/M services) with 97161-97168 (PT and OT evals and re-evals).
  
These code pairs cannot be billed together, even with a modifier, as these code pairs have a status indicator of “0.” Thus, when these code pairs are billed together, only CPT codes 99281-99285 are eligible for payment.
Over the last 10 months, APTA has been advocating to CMS that they remove the edits for these code pairs. APTA most recently sent a request to CMS and the NCCI contractor in early October, wherein we again urged them to remove these edits. CMS has assured us that they are still considering our request. AOTA also has asked CMS to remove these restrictive edits.

APTA also brought our concerns about these edits to the attention of the American Hospital Association. However, AHA indicated that they had not heard from any of their member hospitals regarding concerns with these edits. Thus, we’ve been asking APTA members who work in the hospital setting to urge their hospital to reach out to AHA and ask the association to advocate for removal of these edits. In addition, we’re encouraging individual PTs and/or their hospitals to reach out to CMS and urge them to remove these edits. CMS can be contacted via: NCCIPTPMUE@cms.hhs.gov.

Some suggested talking points when reaching out to CMS:

    •    As a physical therapist that works in the hospital setting, I strongly recommend that CMS remove the PTP edits associated with CPT codes 99281-99285 and 97161-97164.

    •    The ED E/M services and physical therapy evaluation or re-evaluation do not overlap, and are always separate and distinct services if in no other way than that they are always provided by different practitioners. As stated in the CPT manual, one function of the emergency department visit is to coordinate care with other qualified health care professionals consistent with the nature of the problem and the patient’s and/or family’s needs.

    •    The restrictive PTP edits for CPT codes 99281-99285 and CPT codes 97161-97164 impose a significant penalty on code combinations that represent standard and necessary care, fail to align with the current practice of care, and negatively impact the ability of hospitals to implement best practices. Further, the edits prevent physical therapists from serving those in immediate distress in the emergency setting while hindering their ability to work as part of an interprofessional team.

    •    The physical therapy profession is responsible for managing disease and disability for individuals across the life span, optimizing movement to improve the human experience. CMS must promote policies that improve access to physical therapy, not limit it.

    •    To better support the effective and efficient treatment of a patient’s condition and avoid delay of a meaningful intervention, I strongly recommend that CMS remove the PTP edits for CPT codes 99281-99285 and CPT codes 97161-97164
 
Should you have any questions or would like additional information, please contact advocacy@apta.org.


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Preferred One Authorization Process  9-13-2020 Update

What you might not know about Preferred One’s prior authorization policy may limit reimbursement for your services.  


The Payor Advocacy Workgroup APTA Minnesota (workgroup of the Payment Committee) recently met with Preferred One regarding their prior authorization policy. Currently, Preferred One does not allow retro authorization for services provided prior to an authorization request being submitted. We have heard from many members that this policy is limiting their ability to be paid for treatment provided on the day of the evaluation visit. In the meeting with Preferred One, we were informed of a specific sequence of work that, if followed, you can expect to get paid for evaluation and treatment on the first visit, if the patient and documentation meets the requirements of treatment in the Preferred One policy. Read on for valuable information.


For plans that require authorization:  PreferredOne does not retroactively authorize for treatment, but will pay for treatment if deemed medically necessary via the following process.


1.  Upon scheduling, notify PreferredOne of the upcoming appt for Patient X via the same communication route of requesting authorization.  This serves as an alert for upcoming services.


2.  If the advance alert is completed, and treatment is deemed medically necessary on day of evaluation, PreferredOne will reimburse for the treatment completed prior to authorization request completion.


3.  If treatment is not deemed medically necessary, PreferredOne will not reimburse the treatment even when the advanced alert is completed.
 
In order to ensure payment for treatment, the following options are available:


1.  Once patient is scheduled, notify PreferredOne of upcoming visit – serves as an alert that member will be coming in for services. (above process)


2.  If treatment is provided on date of the evaluation, submit authorization request on same day.


3.  If additional treatment is needed, do not treat patient until authorization request has been submitted. You may want to consider authorization submission as a requirement prior to scheduling subsequent visits in order to avoid denials due to lack of authorization.


*The Payor Advocacy Workgroup serves APTA Minnesota physical therapists and physical therapist assistants by advocating on behalf of APTA MN and its members on issues relating to payment, payment policy, and restrictive actions by payors affecting payment of physical therapy services. The workgroup meets with the larger payors in the state on a quarterly basis. Submit your payor or payment issues to the workgroup here.

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BCBS Announces Postpones Change in Professional Liability Coverage


APTA Minnesota is pleased with the decision as the $2M/$4M requirement would add additional cost for physical therapy practices that are contracted with BCBS to treat their members.

Read the full bulletin here.

BCBS had previously announced that the minimal requirement for professional liability insurance by Physical Therapy providers will increase to $2 million per incident and $4 million aggregate, effective July 1, 2019.

APTA Minnesota is pleased with the decision as the $2M/$4M requirement would add additional cost for physical therapy practices that are contracted with BCBS to treat their members.

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BCBS Announces New Appeals Policy affecting Prior Authorization Requirements for Physical Therapy Services 

APTA Minnesota is pleased to inform members that Blue Cross and Blue Shield of Minnesota announced a new Appeals Policy which includes a change to the prior authorization requirement for physical therapy services. The updated policy, Final OP Therapy and Chiro PA Changes Bulletin P34-19.pdf can be accessed at the BCBS MN website using the link http://bit.ly/2Ud3AMk  


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Committee Chair

 Lori Froehling and Craig Johnson

Purpose

The Payment Committee serves as a resource to APTA Minnesota members regarding physical therapy payment and reimbursement issues, and to partner with the Government Affairs Committee to enhance relationships with third-party payers through dialogue and education regarding the practice of physical therapy. The Payment Committee includes members from all areas of physical therapy practice; each member contributes to issues, concerns or questions relating to their area of expertise.

Goals

  • Utilize expertise to respond to any member(s) that may have questions, concerns or issues regarding payment or reimbursement

  • Keep an ongoing log of questions and responses in the chapter office which will be used to drive educational offerings as a member benefit



Associated Workgroups

Payor Advocacy Workgroup

Contact the Committee Chair

Would you like to know more about this committee? Are you interested in volunteering your time? If you have a comment, question, or would like to volunteer, click here to fill out the contact form. The committee chair will be in touch with you soon.

 

 





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