Surprise CMS Coding Changes Are Lowering PT and OT Reimbursements

On Thursday Jan 2nd Medicare announced two coding changes related to billing Medicare evaluations.

Not complying with these changes will result in lower reimbursements.

Systems 4PT has automated the workflows related to both rules.  Here’s what’s changed:

New Medicare Change #1:

If the payer is Medicare, and if 97140 is charged on the eval visit, the 97140 code must be accompanied with the 59 modifier, which must be defended in the documentation.

If the 59 modifier does not accompany 97140 on an eval, 97140 is not reimbursed.

New Medicare Change #2:

If the payer is Medicare, neither 97530 or 97150 can be charged on the eval visit.

If either 97530 or 97150 are charged on the eval visit, the codes will not be reimbursed.

Obviously, these are widely used CPT codes and the two new changes listed above threaten to erode your Medicare payments.

How To Fix It:

Over the weekend, Systems 4PT installed HardStop™ validation that warns therapists if they are charging Medicare 97140, 97530 or 97150 together with an evaluation code.

  • If the medical necessity for 97140 is documented, Systems 4PT adds the 59 modifier automatically and the code is fully paid
  • HardStop™ technology blocks therapists from signing a Medicare eval if 97530 or 97150 are charged
    • Validation then guides therapists toward other compliant and defensible coding options that will be fully paid

This technology was in place at 11:50 pm on Sunday night, January 5th.

No other EMR has either acknowledged the Medicare coding surprises or delivered workflows that protect the practice.

This leaves their practices with two options:

  • Submit non-compliant coding that doesn’t get paid, or
  • Absorb further inefficiencies by setting up a system of checks and balances that assures compliance

We’re glad that we spent our New Year’s weekend

keeping our practices compliant, fully paid, and safe.

You don’t have to fear healthcare reform when your EMR has your back.

Systems 4PT has your back.

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