MDS Alert
CMS Implements Part B 'Always Therapy' Service Edits
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Find out which modifiers are required. Background: Therapy services that can be considered outpatient therapy - including speech therapy and occupational therapy, together, and physical therapy - are subject to cost caps. The Centers for Medicare and Medicaid Services requires particular modifiers (GN, GO, or GP) on certain Healthcare Common Procedure Coding System codes to designate the correct services and respective expenses toward the therapy cap. Therapists in private practice (TPPs), physicians, and some nonphysician practitioners can furnish professional claims for outpatient therapy services. Update: "All OPT services furnished by TPPs are always considered therapy services, regardless of whether they are designated as 'always therapy' or 'sometimes therapy,' and the appropriate therapy modifier must be included on the claim. However, it may be clinically appropriate for physicians and NPPs to furnish OPT services that have been designated 'sometimes therapy' codes outside a therapy plan of care - in these cases, therapy modifiers are not required and claims may be processed without them," CMS said in a Dec. 21, 2017, Change Request. "These claims represent noncompliant billing by physicians, NPPs, and TPPs and hamper CMS' ability to properly track the therapy caps and analyze claims data for purposes of Medicare program improvements. This CR's requirements will create new edits for Medicare professional claims processing systems to return claims when 'always therapy' codes and the associated therapy modifiers are improperly reported," CMS said. There are no changes to the actual policy, according to the Change Request. The requirements listed "improve the enforcement of longstanding existing instructions," the Change Request says. Read more about CMS's therapy service designations, therapy codes, and therapy modifiers in the Change Request and attachment here: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R3936CP.pdf. Resource: Find out more about the annual therapy update: https://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapyUpdate.html.
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