Physical and occupational therapy are in for big changes in the next few years, as even a cursory glance at the latest news from the Centers for Medicare & Medicaid Services (CMS) shows. Significant changes to payment, reporting, and billing will have serious consequences for your practice, says coding instructor Margie Scalley Vaught in her “Physical Therapy & Occupational Therapy Coding Updates for 2019” webinar.
What’s new: Updates to physical and occupational therapy HCPCS coding and reporting stem from both the Bipartisan Budget Act of 2018 and the CY 2019 Medicare Physician Fee Schedule (MPFS) Final Rule.
To code at your best, you’ll need to know the ins and outs of these regulations, and how they change—or don’t—the therapy cap, functional limitation reporting (FLR), HCPCS codes, and new modifiers for 2019. Here’s a brief summary:
Cap Repeal: Is the Cap Really Gone?
If you’re confused about the status of the therapy cap, you’re not alone. Here’s a briefing on the Bipartisan Budget Act of 2018, which, as far as billing and coding go, made the following changes:
- Permanently repealed Medicare’s Outpatient Therapy Cap, while leaving a “soft cap”—more commonly referred to as a “threshold amount.”
- Upped the KX modifier threshold by 1.5 percent, plus a bit of rounding. The “soft cap” for combined physical therapy and speech and language therapy is $2,040, while OT by itself is $2,040.
So what changed? For patients, they won’t have to worry about paying the full cost of outpatient physical therapy (PT), speech and language therapy (SLP), or occupational therapy (OT). For your practice, because of the threshold amount, your claim workflow hasn’t really changed.
But: Do take care when reporting for services above the threshold amount. These claims must include the KX modifier as a confirmation that the services provided were medically necessary, and medical necessity needs to be present in the documentation. The general rules on when to use the KX modifier remain unchanged.
New Modifiers: Clarify What ‘In Part’ Means
Also: Don’t forget to add two new modifiers to your physical and occupational therapy HCPCS coding arsenal—one for physical therapy and another for occupational therapy. They are:
- CQ: to report outpatient PT services furnished in whole or in part by a PT assistant
- CO: to report outpatient OT services furnished in whole or in part by an OT assistant
Be careful: In response to initial confusion, CMS clarified that to qualify as “in part,” the assistant must provide at least 10 percent of the reported therapy service.
You still have time to apply these modifier-use rules. The Bipartisan Budget Act of 2018 required that these modifiers be established by January 1, 2019, but they won’t be required on claims until January 1, 2020. Even then, the reduction in payment (85% differential) won’t be effective until January 1, 2022.
FLR Reporting: HCPCS Codes on the Way Out, Not Gone Yet
So the Bipartisan Budget Act affects your reporting a fair amount for 2019. What may have an even bigger impact is the upcoming year’s MPFS Final Rule. According to this year’s Rule, FLR won’t be a source of grief for you anymore. These reporting requirements are gone, meaning you no longer have to select or report FLR codes and modifiers such as HCPCS codes G8978-G8999, G9185-G9186, or severity modifiers CH-CN.
Watch Your Step: Don’t throw everything FLR out the window, however. The 42 non-payable HCPCS codes associated with FLR are staying for another year.
Why? The delay should give you and insurers more time to update policies and billing systems, with the ultimate goal of avoiding an unnecessary amount of rejected claims. More importantly, since these HCPCS codes are sticking around for another year, you can still use six of the remaining G-codes for MIPS-eligible PT, OT, and SLP in 2019.
All the Latest Updates in One Place
Modifier changes, reimbursement adjustments, and eliminated FLR reporting—that’s a lot to take in. But you can learn strategies to cope with these changes, assures Margie Scalley Vaught in her webinar, “Physical Therapy & Occupational Therapy Coding Updates for 2019.” Don’t let physical therapy HCPCS codes or changes to OT billing trip you up in the New Year: Get audit ready within an hour with Vaught’s information-packed session to set your practice straight!
