Knowledge Base - Full Library

Influenza Vaccine Payment Allowances - Annual Update for 2016-2017 Season

• Transmittal 3611, Change Request 9758, MLN Matters Article MM9758
• Issued 9/9/2016, Effective 8/1/2016, Implementation by 11/1/2016
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for influenza vaccines provided to Medicare beneficiaries.

Summary of Changes: Provides the availability of payment allowances for the following seasonal influenza virus vaccines.

Coding Revisions to National Coverage Determination (NCDs)

• Transmittal 1708, Change Request 9751, MLN Matters Article MM9751
• Issued 8/19/2016, Effective 1/1/2017, Implementation 1/3/2017
• Affects physicians and other providers submitting claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.

Summary of Changes: The 9th maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs).

October 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)

• Transmittal 3602, Change Request 9768, MLN Matters Article MM9768
• Issued 8/26/2016, Effective 10/1/2016, Implementation 10/3/2016
• Affects providers and suppliers who submit claims to Medicare Administrative Contractors (MACs), including Home Health and Hospice (HH&H) MACs, for services provided to Medicare beneficiaries and which are paid under the Outpatient Prospective Payment System (OPPS)..

Summary of Changes: This Recurring Update Notification describes changes to and billing instructions for various payment policies implemented in the October 2016 OPPS update.

Claim Status Category and Claim Status Codes Update

• Transmittal 3599, Change Request 9680, MLN Matters Article MM9680
• Issued 8/26/2016, Effective 1/1/2017, Implementation 1/3/2017
• Affects physicians, providers, and suppliers who submit claims to Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, and Home Health & Hospice (HH&H) MACs for services provided to Medicare beneficiaries.

Summary of Changes: Updates, as needed, the Claim Status and Claim Status Category Codes used for the Accredited Standards Committee (ASC) X12 276/277 Health Care Claim Status Request and Response and ASC X12 277 Health Care Claim Acknowledgment transactions.

Annual Clotting Factor Furnishing Fee Update 2017

• Transmittal 3607, Change Request 9759, MLN Matters Article MM9759
• Issued 8/26/2016, Effective 1/1/2017, Implementation 1/3/2017
• Affects physicians and other providers billing Medicare Administrative Contractors (MACs) for services related to the administration of clotting factors provided to Medicare beneficiaries.

Summary of Changes: This annually recurring CR announces the update to the Clotting Factor Furnishing Fee.

JW Modifier: Drug /Biological Amount Discarded/Not Administered To Any Patient - Frequently Asked Question

• Issued 8/26/2016, Effective 1/1/2017,FAQs
• Affects Providers and suppliers submitting claims for Part B drugs.

Summary of Changes: An FAQ document concerning use of the JW modifier

End of Temporary Suspension of the BFCC-QIO Short Stay Reviews

• Inpatient Hospital Reviews
• Effective 9/12/2016
• Affects acute care inpatient hospitals, long-term care hospitals, and inpatient psychiatric facilities.

Summary of Changes: BFCC-QIOs will resume initial patient status reviews of short stays to determine the appropriateness of Part A payment for short stay hospital claims.

Medicare Fee for Service National Recovery Audit Program   (April 1, 2016 – June 30, 2016) Quarterly Newsletter              

• Recovery Auditor 3rd Qtr 2016 Newsletter

Summary of Changes: Overpayment and underpayment correction amounts for each RA region and the top issue per region.

Notification of Final Rule Published- Emergency Preparedness

• Survey-and-Cert-Letter-16-38
• Issued 9/8/2016, Effective 11/16/2017
• Affects Medicare and Medicaid Participating Providers and Suppliers.

Summary of Changes: The Emergency Preparedness Rule outlines the requirements for all providers and suppliers in regards to planning, preparing and training for emergency situations.

Q:

Have there been any recent notifications where Medicare Administrative Contractors (MACs) are reviewing professional claims related to denied hospital claims?

 

A:

Yes. In July, Noridian JE posted notification of “initiation of CMS approved cross recovery of professional claims related to denied institutional facet injection services, CPT codes 64493 – 64495; 64635 – 64636.” As a reminder, CMS published Transmittal 534 in August 2014 stating MACs have the discretion of also reviewing “related” Part B claims for services denied by Part A. The MACs are required to post notification of such related reviews. Although this is not good news for physicians, it may help hospitals by improving communication and coordination between hospitals and physicians since both parties now have something at stake.

Do you sometimes feel that your life is a circus? Does this especially apply at times to your role in healthcare? The circus often includes people and animals jumping through hoops – lions, small dogs, clowns - through big hoops, small hoops, or flaming hoops. In Medicare’s clarification concerning reporting “therapy-like” services that appeared in the October 2016 OPPS Update, providers have a choice of hoops.

Before we choose a hoop, let’s consider what exactly Medicare means when they refer to “non-therapy outpatient department services that are similar to therapy services.” Rehabilitative therapy services, that is physical therapy, occupational therapy, and speech language pathology services, are provided by therapists under a plan of care in accordance with Section 1835(a)(2)(C) and Section 1835(a)(2)(D) of the Act and are paid for under Section 1834(k) of the Act. These services require functional limitation reporting and are subject to the therapy cap. Sometimes, hospital outpatients will be provided therapy-like services during the perioperative period of a Comprehensive APC (C-APC) procedure without a certified therapy plan of care. When non-therapy outpatient department services are included on the same claim as a C-APC procedure (status indicator (SI) = J1) or the specific combination of services assigned to the Observation Comprehensive APC 8011 (SI = J2), these services are considered adjunctive to the primary procedure and their payment is included as a packaged part of the payment for the C-APC procedure.

Hoop One

In the July 2016 OPPS Update, CMS put forth a requirement to be effective July 1, 2016, for these non-therapy outpatient department services adjunctive to a C-APC to be reported without HCPCS codes and with revenue code 0940. In comments on the June 8, 2016 Hospital Open Door Forum, CMS stated this change in reporting requirements was due to provider concerns about having to report functional limitation G codes and modifiers with these packaged “therapy-like” services. Provider response to CMS’s explanation was that this solution simply created different problems from the one it solved. Shortly after, CMS delayed the implementation of the reporting change for therapy-like services until October 1, 2016. The October OPPS update gives provider two options for claims received on and after October 1, 2016 for dates of services on and after January 1, 2015. One option continues to be reporting these “non-therapy” therapy services with revenue code 0940 and no HCPCS codes. Hopefully CMS has made modifications to claim processing systems to allow the reporting of revenue code 0940 without HCPCS codes, since this revenue code historically has required the presence of HCPCS codes.

Hoop Two

The second option in the October update for reporting “therapy-like” services adjunctive to C-APCs is that providers can continue to report these with the therapy revenue codes (042x, 043x, and 044x) and with therapy HCPCS/CPT codes. However, if a provider chooses this option, they must follow all the requirements of rehabilitative therapy code reporting, including occurrence codes, therapy modifiers, and the reporting of functional limitation G codes and modifiers. The therapy cap will not be affected since payment for these services is packaged into the comprehensive APC payment.

So do you want to jump through the hoop into the lion’s mouth or the flaming hoop? Your choice, but neither one is without its complications.

Fall is my favorite time of year. How could it not be when kids are going back to school, college football returns, and although the summer heat lingers longer than I would like, we have some spectacular fall foliage. Everything I love about fall at the most basic is consistent from year to year but in truth brings about tremendous change. Maybe it’s my oldest nephew entering high school this year, or the first weekend of regular season football shattering the predictions in the football standings - at the end of the day one constant of fall is change.

The one constant I have seen in health care for more years than I care to think about now is change. Exhibit A: the ICD-10-CM Official Guidelines for Coding and Reporting updates go into effect every fall on October 1st with the start of a new CMS Fiscal Year. In the update, narrative changes appear in bold text. However, with the FY 2017 Guidelines there are some significant changes, of which one in particular has sparked a lot of debate in the Coding and Clinical Documentation Community.

Key NARRATIVE Changes

“With”

“The word “with” should be interpreted to mean “associated with” or “due to” when it appears in a code title, the Alphabetic Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular list. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated. For conditions not specifically linked by these relational terms in the classification, provider documentation must link the conditions in order to code them as related. The word “with” in the Alphabetic Index is sequenced immediately following the main term, not in alphabetical order.”

Code assignment and Clinical Criteria

The New addition to the guidelines, “Code assignment and Clinical Criteria,” is the “hot button” that has sparked much debate as to what this really means.  

“The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient. Code assignment is not based on clinical criteria used by the provider to establish the diagnosis.”

This guidance poses a real dilemma for Professional Coders and Clinical Documentation Improvement (CDI) Specialists as we include clinical indicators when constructing a query for the physician and government contractors have become notorious for denying a claim for lack of clinical indicators in the documentation supporting the coded diagnosis. Unfortunately, I have yet to see, read or hear about a good solution for this guidance.

Zika virus infections

1. “Code only confirmed cases
   Code only a confirmed diagnosis of Zika virus (A92.5, Zika virus disease) as documented by the provider. This is an exception to the hospital inpatient guidelines Section II, H.
   
   In this context, “confirmation” does not require documentation of the type of test performed; the physician’s diagnostic statement that the condition is confirmed is sufficient. This code should be assigned regardless of the stated mode of transmission.
   
   If the provider documents “suspected”, “possible” or “probable” Zika, do not assign code A92.5. Assign a code(s) explaining the reason for encounter (such as fever, rash, or joint pain) or Z20.828, Contact with and *suspected) exposure to other viral communicable diseases.”

Hypertension

With the transition to ICD-10 last October there was one code for Hypertension (I-10). There was no longer a way to differentiate when it was actually a “hypertensive crisis” or “hypertensive emergency.”

As of October 1, 2016, they are back.

“Hypertensive Crisis
Assign a code from category I16, Hypertensive crisis, for documented hypertensive urgency, hypertensive emergency or unspecified hypertensive crisis. Code also any identified hypertensive disease (I10-I15). The sequencing is based on the reason for the encounter.”

 

Documented Pressure Ulcer Stage

There are two new changes for 2017. First being for patients admitted with pressure ulcers documented as healing. “For ulcers that were present on admission but healed at the time of discharge, assign the code for the site and stage of the pressure ulcer at the time of admission.”

The second change is for the patient admitted with pressure ulcer evolving into another stage during the admission. “If a patient is admitted with a pressure ulcer at one stage and it progresses to a higher stage, two separate codes should be assigned: one code for the site and stage of the ulcer on admission and a second code for the same ulcer site and the highest stage reported during the stay.”

 

While I have highlighted a few of the key narrative changes, it is worth noting that there are over 40 narrative changes in the guidelines. Looking for specific changes also made me realize how many times the guidelines advise “when documentation is unclear the provider should be queried” (26 times).

From the CDI Specialist perspective the guidelines provide a good foundation for understanding and appreciating the coding conventions to which Coding Professionals must adhere. They are also an essential read for anyone preparing for the Certified Clinical Documentation Specialist (CCDS) exam.

I encourage Coding Professionals and CDI Specialists to read the entire document and be on the lookout for how to register for our fall Inpatient Coding Updates Webinar that is held annually in October. 

Dilemma:

A patient is admitted through the ER with pleuritic chest type pain, SOB, dyspnea, productive cough, and fever of 100.7. Patient has a previous history of CVA with continuing residual of dysphagia, MI and COPD. CXR shows RLL infiltrate and is treated with IV antibiotics. Patient is also noted to have a positive swallowing study. Discharge diagnosis was community acquired pneumonia (CAP), history of MI, history of COPD, CVA with Dysphagia, and Aspiration Pneumonia. What code would be reported for the patient’s pneumonia?

Solution:

Assign code J69.0 for the aspiration pneumonia only. Even though the physician documents both aspiration pneumonia and community acquired pneumonia, only one code would be reported. Given that CAP is not a type of pneumonia, there is not a code specifically for it like there is for a nosocomial type infection (Y95). When CAP is documented, this is just letting you know that the patient did not acquire the infection through some type of health care organization. 

The phrase “waste not, want not” means to use one’s resources wisely in order to always have plenty and avoid poverty. Although Medicare pays for drug wastage in certain circumstances, they also expect healthcare providers and suppliers to “use drugs or biologicals most efficiently, in a clinically appropriate manner.” But when waste cannot be avoided, starting next year, CMS is requiring reporting that will allow them to identify and monitor billing and payment for discarded drugs under Medicare Part B.

As promised, CMS has released a list of frequently asked questions concerning the use of the JW modifier. The JW modifier indicates that a portion of a drug or biological was discarded or wasted. Currently the use of the JW modifier is at the discretion of the jurisdictional Medicare Administrative Contractors (MACs). For example, Cahaba GBA, MAC for Jurisdiction JJ (Alabama, Georgia, and Tennessee) does not require the reporting of the JW modifier for wasted drugs/biological. In order to be more consistent and better able to track drug wastage, CMS is requiring the use of the JW modifier nationally effective January 1, 2017, in order for providers/suppliers to seek payment for drug/biological wastage.

The JW modifier is to be used on Part B drug claims for discarded drugs and biologicals (hereafter referred to as drugs) when they are in single-use vials or packaging. If uncertain, the information as to whether a drug or biological is single use can be found in the manufacturer’s packaging insert. The discarded drug amount is the amount of a single use vial or other single use package that remains after administering a dose/quantity of the drug to a Medicare patient. Multiple use vials/packaging are not eligible for Medicare payment for discarded amounts.

The JW modifier will mainly be used for reporting drug wastage in physician offices and hospital outpatient departments (including Critical Access Hospitals (CAHs)). Some suppliers such as pharmacies may need to report the JW modifier, but it is unlikely they will have much, if any, drug wastage. Hospital Part B inpatient claims on a 12X type of bill would also report the JW modifier for separately payable drugs. Eligible and participating 340B providers are not exempt from use of the JW modifier.

One of the main things to remember about the use of the JW modifier is that it only applies to drugs that are separately payable, for example drugs with an OPPS status indicator of G (pass-through drugs) and K (separately payable non-pass-through drugs). In the outpatient hospital setting, this applies to separately payable drugs billed for surgical patients, patients in the emergency room, patients in outpatient clinics, and other outpatients receiving separately payable drugs.

This means that drugs that are not separately paid by Medicare do not require the use of the JW modifier. For example:

• Drugs provided in rural health clinics (RHCs) and federally qualified health centers (FQHCs) since these are not separately paid,
• Drugs provided during hospital inpatient admissions (Part A) that are paid under the Inpatient Prospective Payment System (IPPS),
• Drugs given to an outpatient but combined to an inpatient Part A claim under the 3 day payment window rule,
• Packaged drugs, such as drugs with an OPPS status indicator of “N” or an SI of “K” that are bundled with comprehensive APCs (see OPPS Addendum D1 for explanation of services packaged with comprehensive APCs)
• Overfill wastage (CMS has made it clear in the past that overfill, which is any amount of drug greater than the amount identified on the package, is not billable.)

CMS also exempts drugs paid under the Part B drug Competitive Acquisition Program (CAP) although at this time the CAP remains on hold so there is no current list of CAP medications.)

One of the questions not clearly addressed by the FAQs is whether providers and suppliers are required to report drug wastage or can they elect to absorb the cost of discarded drugs. The guidance states that the JW modifier is used in order to obtain payment for the discarded amount of a drug or biological and is not needed if no discarded drug is being billed to the payer. So IF you are going to bill and expect payment for drug wastage, you must use the JW modifier January 1, 2017 and after.

In using the JW modifier on and after January 2017, providers must report the amount of the discarded drug on a separate claim line with the JW modifier. The unit field should reflect the quantity of drug discarded. If the provider is unable to quantify the amount of drug wasted, the JW modifier is not required. Do not report one claim line with combined units for amount of drug administered and wasted. Also realize if the amount of drug administered or the amount of drug wasted is less than the amount described by one HCPCS billing unit, then it is not necessary to use the JW modifier.

Prior to January 1, 2017, providers must follow the directions of their MACs or they may voluntarily report the JW modifier. Providers should check their MACs websites for any specific direction concerning the reporting of the JW modifier prior to the mandatory January 1, 2017 requirement. For example, here is some guidance from a few MACs and you can see that current instructions differ from MAC to MAC – that is why it is important to determine your MAC’s guidance for use of the JW modifier in 2016.

Cahaba GBA - Cahaba DOES NOT require the use of the JW modifier at this time. If providers wish to designate that a portion of a single dose vial is being discarded, please continue to bill the injection on ONE line and add the JW modifier to the procedure code and document the discarded amount in the patents records. Bill for the complete vial, even though part of the vial is being discarded. DO NOT split the billing to two claim lines: one with the JW and one without.

First Coast - For billing purposes, First Coast does not require the use of modifier JW prior to January 1, 2017. Drug wastage is billed by combining on a single line the wastage and administered dosage amount.

NGS - National Government Services does NOT require the use of the JW modifier at this time but providers may choose to use it. Claims will process appropriately with or without the JW modifier. If the JW modifier is used; it should be appended to a separate line for the HCPCS code (separate from the amount administered) indicating the amount (in units) discarded.

One thing CMS and all the MACs agree on is that wastage of the drug must be documented in the patient’s medical record to support the billing of discarded drugs. Here is CMS’s answer to the FAQ concerning documentation of drug wastage:

“CMS expects that providers and suppliers will maintain accurate (medical and/or dispensing) records for all beneficiaries as well as accurate purchasing and inventory records for all drugs that were purchased and billed to Medicare. General guidance on documentation is available in MLN Matters SE 1316. Providers and suppliers should also check with the MAC that processes their Part B drug claims in case additional information on billing and documentation is available at the local level.”

For complete details concerning the JW modifier, see the following CMS guidance:

• MLN Matters Article MM9603,
• Section 40 of Chapter 17 of the Medicare Claims Processing Manual,
• CMS’s FAQ document
• Any information on the JW modifier on your local MAC’s website

Providers should use drugs wisely and efficiently, but if wastage cannot be avoided and the provider wants to be paid for it, then understanding the proper use, reporting and documentation for the JW modifier is critical.

Q:

Our hospital laboratory receives pathology specimens for testing from physician offices and ambulatory surgical centers. Since these are not hospital inpatients or outpatients, is it appropriate to use a type of bill (TOB) 14x like we do for clinical lab tests on non-patients?

 

A:

Per clarification in the August 30, 2016 Hospital Open Door Forum, using a TOB 14x for the technical component of pathology non-patient specimens is appropriate. Non-patients are those patients that are neither inpatients nor outpatients of a hospital, but that have a specimen that is submitted for analysis to a hospital; the patient is not physically present at the hospital.

TRANSMITTALS

October 2016 Integrated Outpatient Code Editor (I/OCE) Specifications Version 17.3

• Transmittal 3591, Change Request 9754, MLN Matters Article MM9754
• Issued 8-12-16, Effective 10-1-16, Implementation 10-3-16
• Affects providers who submit claims to Medicare Administrative Contractors MACs), including Home Health and Hospices (HH+H) MACs, for services provided to Medicare beneficiaries.

Summary of Changes: Quarterly update of the I/OCE. All institutional outpatient claims (which includes non-OPPS hospital claims) are routed through a single integrated OCE to apply claims processing edits.

Medicare Part B Clinical Laboratory Fee Schedule: Guidance to Laboratories for Collecting and Reporting Data for the Private Payor Rate-Based Payment System

• MLN Matters Article SE1619
• Issued 8-8-16
• Affects Medicare Part B clinical laboratories who submit claims to Medicare Administrative Contractors (MACs) for services furnished to Medicare beneficiaries.

Summary of Changes: This guidance includes clarifications for determining whether a laboratory meets the requirements to be an “applicable laboratory,” the applicable information (that is, private payor rate data) that must be collected and reported to the Centers for Medicare & Medicaid Services (CMS), the entity responsible for reporting applicable information to CMS, the data collection and reporting periods, and the schedule for implementing the new CLFS

Coding Revisions to National Coverage Determination (NCDs)

• Transmittal 1708, Change Request 9751, Transmittal 1708
• Issued 8-19-16, Effective 1-1-17 unless otherwise noted, Implementation 1-3-17

Summary of Changes: The 9th quarterly maintenance update of ICD-10 conversions and other coding updates specific to national coverage determinations (NCDs)

 

OTHER UPDATES

2017 ICD-10-CM and ICD-10-PCS 2017 Guidelines

• ICD-10-CM Guidelines are available on the CDC and CMS Websites http://www.cdc.gov/nchs/icd/icd10cm.htm and https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-CM-and-GEMs.html
• ICD-10-PCS Guidelines on CMS Website https://www.cms.gov/Medicare/Coding/ICD10/2017-ICD-10-PCS-and-GEMs.html

Summary of Changes: To easily identify what is new for the October 1, 2016 start date for the CMS 2017 Fiscal Year, narrative changes appear in bold text. The ICD-10-CM Preface for 2017 found on the CDC website indicates that “ICD-10-CM is the United States’ clinical modification of the World Health Organization’s ICD-10. The term “clinical” is used to emphasize the modification’s intent: to serve as a useful tool in the area of classification of morbidity data for indexing of health records, medical care review, and ambulatory and other health care programs, as well as for basic health statistics. To describe the clinical picture of the patient the codes must be more precise than those needed only for statistical groupings and trend analysis.”

Updates to the Clarifying Questions and Answers Related to the July 6, 2015, CMS/AMA Joint Announcement and Guidance Regarding ICD-10 Flexibilities for Physicians

• Questions & Answers pdf
• Released August 18, 2016

Summary of Changes: The ICD-1 flexibilities are set to expire October 1, 2016. Providers should already be coding to the highest level of specificity. The flexibilities were “solely for the purpose of contractors performing medical review so that they would not deny claims solely for the specificity of the ICD-10 code as long as there is no evidence of fraud.”

I absolutely love those television shows of people viewing and buying houses. One doesn’t have to watch many such shows to realize that people have very different taste in the types of houses they prefer. Some like brand-new, sleek and modern homes; some like more traditional homes; and others have a preference for vintage homes with character. But where is the line between “vintage” and just plain old? This distinction may also be applied to other products, items or aspects of our lives – for example, are film x-rays vintage or just old? However you view x-rays (pun intended), film and even computed radiography x-rays are out-of-date. Healthcare payers do not like to pay for out-of-date technology, especially when a newer technology provides more effective and efficient healthcare. As far as x-rays go, we now live in a digital world.

In the 2017 Outpatient Prospective Payment System (OPPS) proposed rule, CMS, in accordance with the Consolidated Appropriations Act of 2016, is proposing to reduce payments for film x-rays. Effective for services furnished during 2017 or any subsequent year, the payment under the OPPS for imaging services that are X-rays taken using film shall be reduced by 20 percent. CMS is also proposing that these services be identified by the use of a new modifier to be appended to imaging services that are X-rays taken using film. The presence of the modifier will result in a 20% reduction in the payment rate for the imaging service. This payment reduction is not considered an adjustment and will not be budget neutral.

For CYs 2018 through 2022, OPPS payments for X-rays taken using computed radiography will be reduced by 7%. Beginning in 2023 and thereafter, this reduction will be increased to 10%. CMS states that they will address the mechanisms for the reductions in OPPS payment for imaging services that are X-rays taken using computed radiography technology (including the imaging portion of a service) in future rulemaking.

The days of attaching a floppy film to an x-ray viewer are behind us or at least not worth what they once were. Marcus Welby, M.D. – you are out-of-date … or maybe vintage.

When my son was in college, he fell and broke his leg while playing a pick-up game of basketball. Last year my elderly father fell and broke his leg. Was their rehabilitative therapy experience the same? Hardly. Was the therapist’s time, effort and consideration for the therapy evaluation the same? Hardly. A physical therapy or occupational therapy evaluation for a young, healthy teenager with no other medical conditions is not the same as a therapy evaluation for an elderly patient who has numerous other medical conditions and pre-existing limitations in functional abilities. Beginning January 2017, that fact is being addressed with new CPT codes for rehabilitative therapy evaluations based on complexity.

CMS is proposing to accept the new CPT codes for physical and occupational therapy evaluation and re-evaluation services for 2017. The new evaluation codes are tiered based on the complexity of an evaluation that may vary due to the severity and complexity of the patient’s condition. The current evaluation codes and their respective replacement codes are:

• 97001, PT evaluation will be replaced with three new codes: 97x61, 97x62, and 97x63
• New PT re-evaluation code 97x64 will replace 97002
• 97003, OT evaluation will be replaced with three new codes: 97x65, 97x66, and 97x67
• New OT re-evaluation code 97x68 will replace 97004

As discussed in the Medicare Physician Fee Schedule (MPFS) Proposed Rule , Medicare will not have tiered payments for the new codes, but will continue to make one payment amount for all three levels of evaluation. CMS states concerns about potential risk of upcoding as therapists are learning to use the new codes, the incentive to upcode differential payment rates would create, and unknown utilization of the various levels. Perhaps CMS will reconsider tiered payment rates in the future once the learning curve is past and they have some historical data on code usage. Until then payment for evaluations and re-evaluations will likely be similar to current payment rates.

CMS also identified several other therapy codes they consider to be “misvalued” that may have a negative payment rate adjustment for next year. We will have to wait on the final MPFS rule to know exact payment rates. Those CPT codes are:

• 97032 – unattended electrical stimulation,
• 97035 – ultrasound therapy,
• 97110 – therapeutic exercises,
• 97112 – neuromuscular re-education,
• 97113 – aquatic therapy/exercises,
• 97116 – gait training,
• 97140 – manual therapy,
• 97530 – therapeutic activities,
• 97535 – self care management training,
• G0283 – unattended electrical stimulation other than wound care

Therapy codes continue to be subject to the Multiple Procedure Payment Reduction (MPPR) which means only one unit of the highest paid code reported for a day of service is paid at 100%. Additional units and codes are paid at a reduced payment rate.

See Table 19 on page 350 of the MPFS proposed rule for the complete long descriptions and specific components of each new code. The PT re-evaluation code, 97x64 requires an examination with review of history, standardized tests and measures, and a revised plan of care. CPT 97x68, OT re-evaluation, also requires a revised plan of care based on assessment of the patient’s functional or medical status with an updated occupational profile. Information on the new evaluation codes is summarized in a table you can dowload by clicking here.

Therapists must educate themselves on how to appropriately use the new codes and the documentation required to support the codes. Therapists are used to scrutiny of their documentation to support the services they provide. These new tiered codes add yet another documentation challenge for therapists.