New Home Health Reimbursement Model Takes Effect

Effective January 1^st, the Patient-Driven Groupings Model (PDGM) will be used going forward to determine payment for home health services. Like PDPM in the skilled nursing setting, PDGM seeks to shift payment focus from quantity (volume-based) to quality (value-based) with emphasis on patient clinical characteristics to more accurately describe and reimburse the care provided.

Major changes with PDGM include:

• Payment periods change from 60 day period to 30 day period 
• Elimination of therapy thresholds—number of therapy visits no longer directly impacts reimbursement
• Payment groups based on five key characteristics:

1. Admission Source—Patient setting 14 days before home health admission
2. Timing—Early or late
3. Clinical Grouping—Primary reason person is receiving home health services
4. Functional Impairment Level—Indicated on the OASIS
5. Comorbidity adjustment

PDGM provides multiple opportunities for occupational therapy practitioners to share our unique expertise and value within the home health setting. With a need to accomplish much with fewer visits, the quality and purpose of our home health interventions and education, both during our visits and between visits, must be focused and occupation-based to be effective. AOTA has many available resources on their website, and we encourage you to seek out additional information as needed to bolster your knowledge for your own practice. As with PDPM, if you experience or have experienced fallout from employers or providers related to PDGM implementation that has negatively impacted patients and their access to quality, skilled services, please reach out to let us know at [email protected], and copy [email protected]. 

Additional resources for PDGM:

AOTA Resources

CMS Resources

New NCCI Edits: No 97530 and 97150 with OT Evaluation Codes

In an unusual move, the Centers for Medicare and Medicaid Services (CMS) released changes to the National Correct Coding Initiative (NCCI) edits on January 1^st which no longer allow for two common CPT® codes to be used with evaluation codes. The codes 97530 (therapeutic activities) and 97150 (therapeutic procedures, group, 2 or more individuals) were no longer able to be billed on the same day as occupational therapy evaluation or re-evaluation codes. This was an unexpected and unannounced change, of which AOTA and APTA received no prior warning or chance to provide comment as they usually do. 

AOTA opposed changes to the NCCI edits related to billing changes. Following advocacy efforts from AOTA and other professions, the NCCI edits for occupational therapy evaluations are being reversed.

The American Medical Association (AMA) has approved two new CPT® for cognitive interventions that are included in the 2020 fee schedule and may be billed by occupational therapy practitioners. These codes replace the G0515 code, but the description matches that of the 97127 code and falls much more in line with occupation-based interventions typically provided by occupational therapy.

The new codes are:

• 97129    Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive functioning, problem solving and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks), direct (one-to-one) patient contact; initial 15 minutes

• 97130    Each additional 15 minutes

Code 97130 is an add-on code. It will need to be billed in addition to 97129 whenever more than one 15-minute unit is performed. Code 97129 will only ever be billed once per visit. Code 91730 will never be billed alone.

OTA Modifier Requirement Begins for Medicare Part B

The Balanced Budget Act of 2018 called for a payment adjustment for services rendered by an therapy assistant versus a therapist. The CY2020 Medicare Physician Fee Schedule final rule indicated that while the 15% payment reduction would not go into effect until 2022, the modifier requirement would go into effect beginning January 1, 2020.

The modifier CO (for occupational therapy assistants) and CQ (for physical therapist assistants) are required to be added to billing in addition to traditional GO and GP modifiers. Modifiers should be added when an assistant has provided greater than 10% of the therapy service. 

From AOTA, these were changes CMS made to the final rule following many comments from concerned practitioners about this policy:

1) Concurrent Services: CMS acknowledged that it is not appropriate to reduce payment when an OT and an OTA are working concurrently on the same patient. The OTA modifier will only apply to time where the OTA is performing the service independently.

2) Units of Service Furnished Separately: CMS acknowledged that it is more appropriate to apply the OTA modifier at the unit level rather than at the service level. The OTA modifier calculation will apply to untimed codes and to timed codes at the 15-minute unit level. For example, when the OTA performs 15 minutes of 97530 and the OT performs 30 minutes, the modifier should be applied to one 15-minute unit of 97530 rather than to all three units.

3) Administrative Burden: CMS acknowledged that an additional documentation requirement would result in undue administrative burden. CMS reminded practitioners that the documentation should be sufficient to support the codes billed and the units applied to the modifier.

Please see the AOTA website link below for specific modifier scenarios and examples.

(Retrieved from https://www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Coding/2020-OTA-Payment-Modifier-Requirement.aspx)