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2017 CPT® codes more accurately report and justify reimbursement for providers of physical medicine


30th November 2016

New physical therapy (PT), occupational therapy (OT), and athletic training (AT) evaluation codes are the first significant changes to CPT® physical medicine and rehabilitation codes in two decades. The new tiered evaluation codes also introduce separate sub-heads for PT, OT, and AT evaluations, but groups them together. This will help coding and billing in clinics and facilities offering all three services.

PT is based on Clinical Decision Making. The PT codes - three evaluation and one re-evaluation-now consider:

  • • Patient’s history
  • • Examination results
  • • Clinical decision-making
  • • Development of the care plan

97161 Physical therapy evaluation: low complexity, requiring these components:

  • • A history with no personal factors and/or comorbidities that impact the plan of care;
  • • An examination of body system(s) using standardized tests and measures addressing 1-2 elements form any of the following: body structures and function, activity limitations, and/or participation restrictions;
  • • A clinical presentation with stable and/or uncomplicated characteristics; and
  • • Clinical decision making of low complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome.
  • • Typically, 20 minutes are spent face-to-face with the patient and/or family.

OT Is Based on Occupational Performance

OTs also get a new set of codes, 97165-97168, that include:

  • • Occupational profile and client history
  • • Assessment of occupational performance
  • • Clinical decision-making
  • • Development of the care plan

OTs are keen to identify and correct performance deficits, and evaluations are meant to identify “the inability to complete activities due to the lack of skills” in one or more of these categories:

  • • Physical skills such as balance, mobility, strength, endurance, motor coordination, sensation, and dexterity
  • • Cognitive skills such as in interacting with tools and materials, carrying out actions, and modifying performance when encountering problems
  • • Psychosocial skills such as interpersonal skills, habits, behaviors, coping strategies, and environmental adaptations

Codes 97165 and 97168 require at least 30 minutes with patient and/or family. The OT must spend as much as 45 minutes to justify reporting 97166, and 60 minutes for 97167 (the highest complexity code).

AT Is Based on Strength and Movement

AT, a growing field in physical medicine, also gets new evaluation codes. Including a patient history and examination, the 97169-97172 series — three for evaluation and one for re-evaluation — follow a similar theme to the PT evaluation codes. ATs must look at a minimum of these elements:

  • • History and physical activity profile
  • • Examination
  • • Clinical decision-making
  • • Development of the care plan

CLIA Waived Tests Effective from 1st January 2017/h2>

Clinical Improvement Amendment of 1988 (CLIA) require a facility to be certified for each test performed. To ensure that Medicare and Medicaid only pay for laboratory tests categorized as waived complexity under CLIA in facilities with a CLIA certificate of waiver, laboratory claims are edited at the CLIA certificate level. The Current Procedural Terminology (CPT) codes for the following new tests must have the modifier QW to be recognized as a waived test; however, some codes in the list below, such as 81002, 81025, 82270, 82272, 82962, 83026, 84830, 85013, and 85651, do not require a QW modifier to be recognized as a waived test. Below are the codes and the dates for which the tests are waived:

  • • G0477QW, February 12, 2016, Greenbrier International, Inc. Assured THC One Step Marijuana Test Cassette
  • • G0477QW, February 12, 2016, Greenbrier International, Inc. Assured THC One Step Marijuana Test Strip
  • • G0477QW, March 18, 2016, Safecare Biotech Urine Test Amphetamine Cassette
  • • G0477QW, March 18, 2016, Safecare Biotech Urine Test Amphetamine Cup
  • • G0477QW, March 18, 2016, Safecare Biotech Urine Test Amphetamine DipCard
  • • G0477QW, March 18, 2016, Safecare Biotech Urine Test Cocaine Cassette
  • • G0477QW, March 18, 2016, Safecare Biotech Urine Test Cocaine
  • • G0477QW, March 18, 2016, Safecare Biotech Urine Test Cocaine DipCard
  • • G0477QW, March 18, 2016, Safecare Biotech Urine Test Marijuana Cassette
  • • 0477QW, March 18, 2016, Safecare Biotech Urine Test Marijuana Cup
  • • G0477QW, March 18, 2016, Safecare Biotech Urine Test Marijuana DipCard
  • • 83986QW, May 13, 2016, Teco Diagnostics OBGYN-VpH Vaginal pH Screening Kit
  • • G0477QW, June 9, 2016, Native Diagnostics International DrugSmart Multi-Panel Drug Screen Cup Tests
  • • G0477QW, June 9, 2016, Native Diagnostics International DrugSmart Multi-Panel Drug Screen Cup with OPI 2000 Tests
  • • G0477QW, June 9, 2016, Native Diagnostics International DrugSmart Dip Multi-Panel Drug Screen Dip Card Tests
  • • G0477QW, June 9, 2016, On-Site Testing Specialists, Inc. On-Site Testing Specialists Multi-Panel Drug Screen Cup Tests
  • • G0477QW, June 9, 2016, On-Site Testing Specialists, Inc. On-Site Testing Specialists Multi-Panel Drug Screen Cup with OPI 2000 Tests
  • • G0477QW, June 9, 2016, On-Site Testing Specialists, Inc. On-Site Testing Specialists Multi-Panel Drug Screen Dip Card Tests
  • • G0477QW, June 9, 2016, On-Site Testing Specialists, Inc. On-Site Testing Specialists Multi-Panel Drug Screen Dip Card with OPI 2000 Tests
  • • G0477QW, June 9, 2016, Alfa Scientific Designs, Inc. Instant-View Multi-Drug Urine Test Cup
  • • G0477QW, June 9, 2016, Alfa Scientific Designs, Inc. Instant-View Multi-Drug Urine Test Panel
  • • G0477QW, July18, 2016, Assure Tech. Co., Ltd. AssureTech Marijuana Dip Card Test
  • • G0477QW, July18, 2016, Assure Tech. Co., Ltd. AssureTech Marijuana Quick Cup Test
  • • G0477QW, July18, 2016, Assure Tech. Co., Ltd. AssureTech Marijuana Strip Test
  • • G0477QW, July18, 2016, Assure Tech. Co., Ltd. AssureTech Marijuana Turn-Key Split Cup Test
  • • G0477QW, July18, 2016, Assure Tech. Co., Ltd. AssureTech Methamphetamine Dip Card
  • • G0477QW, July18, 2016, Assure Tech. Co., Ltd. AssureTech Methamphetamine Quick Cup Test
  • • G0477QW, July18, 2016, Assure Tech. Co., Ltd. AssureTech Methamphetamine Strip Test
  • • G0477QW, July18, 2016, Assure Tech. Co., Ltd. AssureTech Methamphetamine Turn-Key Split Cup Test
  • • G0477QW, July18, 2016, Assure Tech. Co., Ltd. AssureTech Phencyclidine Dip Card Test
  • • G0477QW, July18, 2016, Assure Tech. Co., Ltd. AssureTech Phencyclidine Quick Cup Test
  • • G0477QW, July18, 2016, Assure Tech. Co., Ltd. AssureTech Phencyclidine Strip Test
  • • G0477QW, July18, 2016, Assure Tech. Co., Ltd. AssureTech Phencyclidine Turn-Key Split Cup Test
  • • 87631QW, July 25, 2016 Roche Molecular, Cobas Liat Influenza A/B & RSV Assay
  • • G0477QW, July 28, 2016, Germaine Laboratories, Inc., AimScreen Multi-Drug Urine Test DipDevice
  • • G0477QW, July 28, 2016, Germaine Laboratories, Inc., SafeCup II Multi-Drug Urine Test Cup
  • • G0477QW, July 29, 2016, NexScreen LLC, NEXSCREEN Multi-Drug Urine Test Cup
  • • G0477QW, July 29, 2016, NexScreen LLC, NEXSCREEN Multi-Drug Urine Test Dip Card
  • • 86308QW, August 4, 2016, McKesson Consult Mononucleosis Test Cassette {whole blood}
  • • 87880QW, September 4, 2016, Princeton BioMeditech StatusFirst Strep A

Quality reporting measures under consideration

The Centers for Medicare & Medicaid Services (CMS) released on Nov. 22 the List of Measures Under Consideration (MUC) for 2016. The National Quality Forum (NQF) announced the same day that the Measure Applications Partnership (MAP) has begun its annual review of the list. The list contains 97 measures, including measures for nursing homes, hospitals, clinician practices, and dialysis facilities, among other settings. The focus continues to be on patient outcomes, appropriate use of diagnostics and services, cost, and patient safety.

These measures will be used for public reporting or payment purposes in programs such as the Merit-based Incentive Payment System (MIPS). Other applicable programs include:

  • 1. Ambulatory Surgical Center Quality Reporting Program (ASCQR)
  • 2. End-Stage Renal Disease Quality Incentive Program (ESRD QIP)
  • 3. Home Health Quality Reporting Program (HH QRP)
  • 4. Hospice Quality Reporting Program (HQRP)
  • 5. Hospital-Acquired Condition Reduction Program (HACRP)
  • 6. Hospital Inpatient Quality Reporting Program (HIQR)
  • 7. Hospital Outpatient Quality Reporting Program (HOQR)
  • 8. Hospital Readmissions Reduction Program (HRRP)
  • 9. Hospital Value-Based Purchasing Program (HVBP)
  • 10. Inpatient Psychiatric Facility Quality Reporting Program (IPFQR)
  • 11. Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP)
  • 12. Long-Term Care Hospital Quality Reporting Program (LTCH QRP)
  • 13. Medicare and Medicaid EHR Incentive Program for Eligible Hospitals (EHs) and Critical Access Hospitals (CAHs)
  • 14. Medicare Shared Savings Program (MSSP)
  • 15. Prospective Payment System (PPS)-Exempt Cancer Hospital Quality Reporting Program (PCHQR)
  • 16. Skilled Nursing Facility Quality Reporting Program (SNF QRP)
  • 17. Skilled Nursing Facility Value-Based Purchasing Program (SNF VBP)

The MUC List is open for public comment through Dec. 2, 2016, at 6 pm ET. MAP will deliver its recommended measures to CMS by Feb. 1, 2017, and publish its final reports in February and March.

Implementation of new ICD-10 codes will lead to increased audits

ICD 10 codes went into effect from 1st October 2016. The new codes include 1,974,311 deleted codes, and 425 revised codes. October 1, 2016, also represents the end of the so-called grace period on ICD-10 coding. Before ICD-10 became official on October 1, 2015, Medicare announced it would not deny claims based on ICD-10 codes or documentation as long as the coder selected the right family, or three-character category.

It is now very important to be aware of the changes as using deleted codes will result in denied claims. And if medical coders are unaware of a new or revised code that is more descriptive of a condition, they might miss out on an opportunity to better establish medical necessity for your care.

Due to the above changes, chances of audits have increased which will include heavy scrutiny of ICD-10 documentation because the grace period is over. Now is a good time to conduct internal audits of diagnosis documentation, or seek out training from trusted experts.

ONC final rule updated to include Health IT Standards to improve security, accountability

The U.S. Department of Health and Human Services (HHS) has released its Office of the National Coordinator for Health Information Technology (ONC) Health IT Certification Program: Enhanced Oversight and Accountability 2017 Final Rule.

The ONC Health IT Certification Program is a voluntary program to provide for the certification of health IT standards, and “to provide assurance to purchasers and other users that a system meets the technological capability, functionality, and security requirements adopted by HHS as described by HealthIT.gov.

The final rule focuses on three key areas:

  • • Direct Review: Provides a regulatory framework for ONC to directly review certified health IT products and take necessary action in circumstances involving: (1) potential risks to public health and safety; or (2) circumstances that present practical challenges for ONC-Authorized Certification Bodies (ONC-ACBs)—such as when issues arise involving multiple certified functionalities or products that have been certified by multiple ONC-ACBs. The final rule also focuses on corrective action plans to address issues and includes an appeals process under the Program for health IT developers that have products under direct review.
  • • Consistent Authorization and Oversight: Establishes a process for ONC to authorize and oversee accredited testing laboratories (ONC-ATLs) to align with ONC’s existing oversight of ONC-ACBs, and facilitates ONC’s ability to quickly, directly, and precisely address testing and performance issues.
  • • Increased Transparency and Accountability: Makes identifiable surveillance results of certified health IT publicly available to advance ONC’s overall commitment to transparency and provide customers and users with valuable information about the performance of certified health IT, including illuminating good performance and continued conformance with Program requirements.

HCPCS Level II changed and will be effective from 1st January 2017

There are more than 600 changes in HCPCS Level II, and many reflect the rise of MACRA’s (Medicare Access and CHIP Reauthorization Act) tracking and electronic medical records (EMR) initiatives. The codes will be effective from 1st January 2017. The codes include 278 new codes and modifiers. 145 codes will be discontinued. There are 147 codes whose descriptions have changed, and 37 with new payment rules. Code, S3854, has been reinstated. The changes are at least a third more than in a “usual” year.

A handful of description changes and new codes disrupt the A and E sections. Most changes are in the dynamic G code section. Of the 1,528 G codes, 213 are new and 108 are discontinued. Changes to descriptions or payment affected another 80 G codes. Reflecting the consolidation of quality programs resulting from the implementation of MACRA beginning January 1, 2017, most of the new codes help providers start tracking care for quality based payment boosts in 2019.

New injections for colchicine, argatroban, gatifloxacin, aripipazole lauroxil, and infliximab included in the J codes, which primarily report non-oral drugs. Several payment and BETOs changes are made in the J codes. Durable medical equipment codes in the K and L sections, along with the P codes remain unchanged.


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