With the start of the new year comes new provisions for therapy documentation and billing. The Centers for Medicare & Medicaid Services (CMS) issued the 2022 Medicare Physician Fee Schedule Final Rule back in November; however, with many regulatory changes going into effect this month, there are a few key points providers may want to review pronto.
This is especially true for updates to the physical therapist assistant (PTA) and occupational therapist assistant (OTA) modifiers, CQ and CO, as well as to the Medicare telehealth services list. If you want to remain current with recent hot topics surrounding therapy documentation and billing, you’ve come to the right place. Take a look at this year’s most prominent changes, plus the top billing red flags to avoid in 2022.
Recent Changes to Assistant Billing and Modifiers
Recent updates to assistant billing and CQ and CO modifiers have been several years in the making. In fact, the first piece of legislation to establish a payment reduction for services provided by PTAs and OTA to Medicare Part B beneficiaries was the Bipartisan Budget Act of 2018 — despite the ultimate updates to reimbursement being slated for this year.
This year, the 2022 Final Rule implemented what the Bipartisan Budget Act originally outlined: A 15% discount to payments under the Medicare Physician Fee Schedule for therapy that is provided, in whole or in part, by a PTA or OTA. CQ and CO modifiers will now trigger a 15% reduction that can be applied to the allowed charge after the beneficiary co-payment, or 15% off of the 80% allowed charge of the fee schedule rate.
The 2022 Final Rule outlined key modifications to the de minimis standard when one unit of a timed therapy service remains to be billed and to specific “two remaining unit” cases. CMS provides several examples of these scenarios in the final rule and on their website, and providers are encouraged to read the specifics straight from the source.
Updates and Clarity Surrounding Telehealth
In the 2022 Final Rule, CMS reiterated that PTs, OTs, and SLPs are eligible providers of telehealth services under Medicare Part B, for the duration of the COVID-19 Public Health Emergency (PHE), as long as it is allowed by state law.
Telehealth services provided under Medicare Part B are to be reported with modifier 95 on both professional and institutional claims during the PHE. In the final rule, CMS extended the use of certain therapy services added to the Medicare telehealth services list on a Category 3 basis through December 31, 2023.
What may complicate matters is that CMS has stated they cannot add therapists as eligible providers of telehealth outside of the COVID-19 PHE, so therapists will be unable to provide and bill for telehealth once the PHE ends — despite several of the codes remaining available through the end of 2023. The Telehealth Extension Act was recently introduced to allow PTs, OTs, and SLPs to provide telehealth services two years post-PHE; however, there is no verdict there yet.
Billing Tips and ‘Red Flags’ Garnered from 2021
To round off the hot topics in therapy documentation and billing are a few billing red flags recognized in 2021 that you will want to avoid in 2022. One of the most prominent updates to be aware of is the October 2021 elimination of ICD-10-CM code M54.5 (low back pain) due to not being specific enough.
Many therapists have already navigated through this change at this point; however, if you have not, be sure to update your current plan of care to reflect a more specific code (such as M54.41 lumbago with sciatica, right side or S39.012 strain of muscle, fascia, and tendon of the lower back). Likewise, always code to the most specific code available and use left, right, and bilateral when possible to decrease the chances of denials.
Another ICD-10 coding red flag to avoid in 2022 is the Excludes1 rejection or denial, when two specific codes should not be billed together. Many payers placed a temporary moratorium on ICD-10 edits, but this was lifted in 2021, and providers are starting to see rejections and denials for the Excludes1 edit. Therapists must work closely with their billers and billing companies to address any denials related to diagnosis coding to ensure accuracy and proper payment.
Finally, both 2020 and 2021 saw several changes to the National Correct Coding Initiative (NCCI) Procedure to Procedure Edits, which, while eventually simplifying billing for Medicare Part B once the dust settled, left therapists in a challenging situation when it comes to non-Medicare payers. Humana, Aetna, and UHC implemented some of the changes made by CMS, but not on the same timeline or in the same way.
Instructions were ever-changing throughout 2021 and remain confusing as we head into the new year. If the NCCI Edits are not followed as outlined by each payer, claims (or specific line items on the claim) will likely be rejected or denied. The bottom line? Check with each payer for their NCCI edit policy and work closely with your billing partner to resubmit claims and/or appeal denials. Make sure you are paid for what you provide.
Looking for More Information?
If you’re looking for more information on how the 2022 Final Rule can impact your rehab therapy business, tune into this latest webinar, “Hot Topics in Therapy Documentation and Billing.” Hosted in conjunction with the National Association of Rehabilitation Providers and Agencies (NARA) and Lincoln Reimbursement Solutions, this webinar is loaded with details regarding calendar year 2022 regulations and other key regulatory and billing topics.