Wiki Medicare PT coding denial - 97140 and 97150

[nolanspade]

Hello,

We billed Medicare for 97140-59 and 97150. They paid the latter but denied the former stating that an accompanying code was not billed. I looked up NCCI edits and RVU values, the RVU values on 97140 are larger, so why is 97150 the column 1 code??

Does anyone have any input as to why the 97140 is not paying? According to CPT, it is not an add-on, it is a standard 1:1 15 minute incremental PT.

 

[jkyles]

Hi there, the higher paying code isn't always the column 1 code. I recommend checking your MAC to see if it has any detailed information on how to report the services and also to determine whether there's a claims processing issue on their end. Otherwise you'll need to go through the appeals process.

 

[amyjph]

Agree, the higher RVU is not always the column 1. If you look it up the 97150 is Major Code/Column 1, 97140 is Minor Code/Column 2.
According to this link below, you would need a 59 on both provided the documentation supports it and they were clearly two separate, distince services.
This is an old link but I believe (at least this part) still applies. You would want to double check any other guidance because of all the changes. https://www.cms.gov/medicare/billin..._part_b_billing_scenarios_for_pts_and_ots.pdf
"The therapist would use the -59 modifier to bill for both group therapy and individual therapy CPT codes to distinguish that the two coded services represent different sessions or separate encounters on the same day. Without the -59 modifier, payment would be made for the lower-priced group therapy CPT Code, in accordance with CPT/CCI rules. The CCI edits are based upon interpretation of coding rules.

11 Part B Billing Scenarios for PTs and OTs (Individual vs. Group Treatment) | CMS

11 part b billing scenarios for pt's and ot's for Therapy Services

www.cms.gov