Physical Therapy Billing – Medicare Payment Updates and Policies for 2016

by | Last updated Dec 18, 2023 | Published on Apr 25, 2016 | Resources, Medical Coding News (A) | 0 comments

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Just like any other specialty, Physical Therapy Billing and Coding requires better documentation based on the latest payment policy from accredited insurers. The Center for Medicare and Medicaid Services (CMS) has issued several payment updates and policy changes that will affect outpatient physical therapy and home health providers for the calendar year 2016.

Medicare Proposed Fee Schedule – 2016

Medicare Physician Quality Reporting System (PQRS) Measures

Eligible professionals, including physical therapists who do not satisfactorily report data on quality measures for the January 1, 2016-December 31, 2016 reporting period, will be subject to the 2.0% payment penalty in their fee schedule amount in 2018. CMS’ latest update is that physical therapists in private practice are required to report 9 individual measures (or up to 8) via claims or registry under the PQRS program to avoid this penalty.

Therapy Caps

Providers may obtain an exception to the therapy cap until December 31, 2017. The therapy cap amount for the CY 2016 is $1,960 (up from $1, 92040) for physical therapy and speech language pathology combined, with a separate $1,940 cap for occupational therapy.

Medical Review Process

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) establishes a framework to move Medicare from a largely fee-for-service program to a program that bases payment on quality and improved outcomes. The law also mandates criteria for targeted medical review for certain cases over the $3700 threshold. The manual medical review process is replaced with a new medical review process.

CMS will determine which therapy services to review by reviewing factors such as providers with patterns of aberrant billing practices compared to their peers, providers with a high claims denial percentage or who are less compliant with applicable Medicare program requirements, and newly enrolled providers.

Conversion Factor in Place

For services provided on or after January 1, 2016, CMS implements an update factor of 0.5%. The 2016 conversion factor is $35.8043, which is down slightly from $35.9335 in 2015. The actual impact on individual physical therapy practices will depend on the mix of services provided.

Misvalued Codes

A list of 118 “potentially misvalued codes” has been published by the CMS, which includes 10 CPT codes frequently billed by physical therapists. CMS has recommended reviewing these codes for potential revision of the work values and practicing expense inputs. These codes include:

  • 97032 attended electrical stimulation
  • 97035 ultrasound
  • 97110 therapeutic exercise
  • 97112 neuromuscular reeducation
  • 97113 aquatic therapy with therapeutic exercise
  • 97116 gait training
  • 97140 manual therapy
  • 97530 therapeutic activities
  • 97535 self care home management training
  • G0283 unattended electrical stimulation (non-wound)

Choose an Experienced Medical Billing Service Provider

Professional Medical Billing and Coding Companies stay up-to-date with the latest changes and submit error-free claims accordingly. They provide the service of experienced billing and coding specialists, who are familiar with the current CPT, HCPCS, and ICD 10 codes.

Outsource Strategies International.

Being an experienced medical billing and coding company in the U.S., OSI is dedicated to staying abreast of the latest industry guidelines. Our services provide comprehensive support for the success of your practice.

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