APTA Michigan's Payment Committee is continually meeting with health care professionals and various insurance companies throughout the state of Michigan to keep our members notified of any changes coming and to advocate for our physical therapy professionals. As a benefit to our membership, APTA Michigan members are notified immediately of any policy changes or deadlines to an insurance plan or group.

Not all Payment questions can be treated the same way. Please email contact@aptami.org if you have a specific question as it relates to Payment.

Payment News:
 

Medicare/Medicaid Billing - Policy regarding NCCI Edits is Revised - Update April 24

posted: April 24, 2020

http://www.apta.org/PTinMotion/News/2020/04/21/NCCIWin/

Life just got a little easier for PTs dealing with CMS National Correct Coding Initiative edits, known as NCCI edits, that prevented reimbursement for certain activity and evaluation codes when used on the same day unless a modifier was appended to the claim. In response to APTA's efforts to show how the coding changes were impacting care and complicating payment, CMS has backed off on many of the edits that were making reimbursement problematic, likely in large part due to the burden being imposed on providers by the COVID-19 public health emergency.

The Coding Changes
In private practice and institutional settings, PTs are now able to pair the following code combinations without the use of 59 or X modifiers:

97530 with 97116
97161 with 97140
97162 with 97140
97163 with 97140
99281-99285 with 97161-97168
97110 with 97164
97112 with 97164
97113 with 97164
97116 with 97164
97140 with 97164
97150 with 97110
97150 with 97112
97150 with 97116
97150 with 97164

There are additional edit changes as well, and APTA’s National Correct Coding Initiative webpage includes a table of the common edits that remain. Check back regularly as some of these edit changes may be temporary and could be reversed after the COVID-9 public health emergency ends.

Which Payers These NCCI Edit Changes Apply to
Medicare and Medicaid programs follow CMS’ NCCI procedure-to-procedure edits. Additionally, most insurers also follow the NCCI PTP edits. As such, APTA recognizes that providers may receive denials on the commercial side related to these edits if they fail to use the applicable 59 or X modifier. Commercial payers may not realize the files have been updated. APTA encourages providers to use the information in this article and found on the CMS PTP Coding Edits webpage to communicate with commercial payers regarding these edit changes.

 

 

Tricare PTA Services - New Update April 22

posted: April 24, 2020

APTA announced that  the Department of Defense (DoD) released a final rule to add licensed or certified PTAs as TRICARE-authorized providers operating under the same qualifications established by Medicare. Services must be furnished under the supervision of a TRICARE-authorized licensed physical therapist.

This rule says that direct supervision will be required in a private practice setting. General supervision will be required in all settings other than private practice. These guidelines are in line with the Medicare supervision requirements.

The rule is effective on April 16, 2020.

Additional Update April 22:  APTA Advisory: TRICARE Manual Updated to Recognize PTAs as Authorized Providers - April 22, 2020

Don't forget to use the CQ modifier if more than 10% of a service is furnished by a PTA.

TRICARE, the health insurance system used throughout the military, announced that it has officially revised its policy manual to recognize PTAs (and occupational therapy assistants) as authorized providers, outlining the rules and requirements governing assistant qualifications, scope of practice, supervision, and reimbursement.

Now it's up to TRICARE contractors to do the same within approximately 30 days.

As reported earlier, beginning with date of service on April 16, PTAs are recognized as authorized providers under TRICARE and thus eligible for reimbursement for covered services rendered to TRICARE beneficiaries.

Take note: The CQ modifier must be appended to the claim when more than 10% of an outpatient physical therapy service is furnished by the PTA. Check out APTA’s Quick Guide to Using the PTA Modifier.

The presence of the modifier shouldn't impact claims processing. However, if claims are denied, they may need to be resubmitted if the claims are sent to contractors before they fully implement the change.

http://www.apta.org/PTinMotion/News/2020/04/22/TRICAREManualUpdatePTAs/

 

Guide to Access BCBSM Provider Manuals

posted: August 22, 2018

Following our meeting with BCBSM on May 11, 2018, the MPTA reported that BCBSM was moving to a vendor-based auditing program for its PPO, similar to what is currently being used for its Plus Blue product, starting this summer 2018. BCBSM stressed that this program is not being used as a utilization

management tool. Rather, it is a tool for fiduciary responsibility to ensure that policies and procedures are being followed and will be equally implemented across all health care providers and settings. Providers will be selected for audit based on computerized algorithms. Thus, it is difficult to predict for a given practice whether audit risk will increase or decrease under this new system.

In response to MPTA’s concern about transparency of auditing criteria, BCBSM stated that the criteria are the policies and procedures in the applicable Provider Manuals.  However, actually finding and accessing the Provider Manuals can be a substantial challenge.  Therefore, MPTA has outlined the requisite steps below:

Log onto the BCBSM website “Provider Secured Services”

Click “webDENIS” (must have webDENIS access)

Choose “Provider Manual”

     You will have a choice of 5 different Provider Manuals: 

      1) BlueCross PPO Provider Manual     click to choose

          click provider type  Independent Therapist or Freestanding Out Patient PT

          Search and you will get categories / chapters to choose from.  This particular manual is

          for therapies.

      2) BCN Provider Manual  

           When you make this choice, you must go through the manual to find the chapters    

           that refer to therapy.

     3) Blue Cross Medicare Plus Blue PPO Provider Manual 

     4) Blue Cross Medicare Private Fee for Service Provider Manual

     5)  Blue Cross Complete Provider Manual (for managed Medicaid)

           When you choose manuals 3,4 or 5 you must scroll through the index to find the

           chapters and pages that refer to therapy.  Unfortunately, there is no short cut to specific sections

           in these three manuals.

 

 

 

Public Health Code Amended to Allow Nurse Practitioners to Prescribe Physical Therapy - Effective April 9, 2017

posted: April 24, 2017

The Physical Therapy Section of the Public Health Code has been amended to allow Advanced Practice Registered Nurses to prescribe physical therapy:

 

PUBLIC HEALTH CODE (EXCERPT)
Act 368 of 1978

***** 333.17820.amended THIS AMENDED SECTION IS EFFECTIVE APRIL 9, 2017 *****



333.17820.amended Practice of physical therapy or physical therapist assistant; license or authorization required; engaging in treatment with or without prescription of certain license holders; use of words, titles, or letters.

Sec. 17820.

(1) An individual shall not engage in the practice of physical therapy or practice as a physical therapist assistant unless licensed or otherwise authorized under this part. Except as otherwise provided in this subsection, a physical therapist or physical therapist assistant shall engage in the treatment of a patient if that treatment is prescribed by a health care professional who is an advanced practice registered nurse as that term is defined in section 17201, or who holds a license issued under part 166, 170, 175, or 180, or an equivalent license issued by another state. A physical therapist or a physical therapist assistant may engage in the treatment of a patient without the prescription of a health care professional who is an advanced practice registered nurse as that term is defined in section 17201, or who holds a license issued under part 166, 170, 175, or 180, or an equivalent license issued by another state, under either of the following circumstances:

(a) For 21 days or 10 treatments, whichever first occurs. However, a physical therapist shall determine that the patient's condition requires physical therapy before delegating physical therapy interventions to a physical therapist assistant.

(b) The patient is seeking physical therapy services for the purpose of preventing injury or promoting fitness.

 

 

(2) The following words, titles, or letters or a combination of words, titles, or letters, with or without qualifying words or phrases, are restricted in use only to those persons authorized under this part to use the terms and in a way prescribed in this part: "physical therapy", "physical therapist", "doctor of physiotherapy", "doctor of physical therapy", "physiotherapist", "physiotherapy", "registered physical therapist", "licensed physical therapist", "physical therapy technician", "physical therapist assistant", "physical therapy assistant", "physiotherapist assistant", "physiotherapy assistant", "p.t. assistant", "p.t.", "r.p.t.", "l.p.t.", "c.p.t.", "d.p.t.", "m.p.t.", "p.t.a.", "registered p.t.a.", "licensed p.t.a.", "certified p.t.a.", "c.p.t.a.", "l.p.t.a.", "r.p.t.a.", and "p.t.t.".

Section 17201:

Sec. 17201. (1) As used in this part:

(a) “Advanced practice registered nurse” or “a.p.r.n.” means a registered professional nurse who has been granted

a specialty certification under section 17210 in 1 of the following health profession specialty fields:

(i) Nurse midwifery.

(ii) Nurse practitioner.

(iii) Clinical nurse specialist.

PUBLIC HEALTH CODE (EXCERPT)
Act 368 of 1978

***** 333.17820.amended THIS AMENDED SECTION IS EFFECTIVE APRIL 9, 2017 *****

 


333.17820.amended Practice of physical therapy or physical therapist assistant; license or authorization required; engaging in treatment with or without prescription of certain license holders; use of words, titles, or letters.

 

Sec. 17820.

(1) An individual shall not engage in the practice of physical therapy or practice as a physical therapist assistant unless licensed or otherwise authorized under this part. Except as otherwise provided in this subsection, a physical therapist or physical therapist assistant shall engage in the treatment of a patient if that treatment is prescribed by a health care professional who is an advanced practice registered nurse as that term is defined in section 17201, or who holds a license issued under part 166, 170, 175, or 180, or an equivalent license issued by another state. A physical therapist or a physical therapist assistant may engage in the treatment of a patient without the prescription of a health care professional who is an advanced practice registered nurse as that term is defined in section 17201, or who holds a license issued under part 166, 170, 175, or 180, or an equivalent license issued by another state, under either of the following circumstances:

(a) For 21 days or 10 treatments, whichever first occurs. However, a physical therapist shall determine that the patient's condition requires physical therapy before delegating physical therapy interventions to a physical therapist assistant.

(b) The patient is seeking physical therapy services for the purpose of preventing injury or promoting fitness.

(2) The following words, titles, or letters or a combination of words, titles, or letters, with or without qualifying words or phrases, are restricted in use only to those persons authorized under this part to use the terms and in a way prescribed in this part: "physical therapy", "physical therapist", "doctor of physiotherapy", "doctor of physical therapy", "physiotherapist", "physiotherapy", "registered physical therapist", "licensed physical therapist", "physical therapy technician", "physical therapist assistant", "physical therapy assistant", "physiotherapist assistant", "physiotherapy assistant", "p.t. assistant", "p.t.", "r.p.t.", "l.p.t.", "c.p.t.", "d.p.t.", "m.p.t.", "p.t.a.", "registered p.t.a.", "licensed p.t.a.", "certified p.t.a.", "c.p.t.a.", "l.p.t.a.", "r.p.t.a.", and "p.t.t.".

 

 


eviCore Clinical Criteria Guidelines Effective 2/14/20
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Michigan Medicaid
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  • APTA Michigan Comments on Proposed Home Health Policy Changes - July 10, 2019

APTA Michigan Correspondence Re: eviCore
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  • APTA Michigan Email to BCBSM Re Direct Access Resources August 24, 2019
  • APTA Michigan Letter to BCBSM July 26, 2019
  • APTA Michigan Letter to BCBSM 3.22.19
  • APTA Michigan Letter to eviCore - October 15, 2018
  • APTA Michigan Email to BCBSM October 15, 2018
  • BCBSM Meeting Minutes - May 11, 2018
  • Summary of Meeting with BCBSM May 11, 2018
  • APTA Michigan Letter to BCBSM April 24, 2018
  • APTA Michigan Meeting with BCBSM and eviCore March 9, 2018
    • Summary - March 9 Meeting
    • Overview of corePath Survey Data
    • APTA Michigan eviCore/corePath Narrative Themes
    • corePath Survey Data Analysis
  • APTA Michigan Letter to BCBSM October 24, 2017
  • APTA Michigan Complaint to Michigan Department of Insurance and Financial Services
  • APTA Michigan Letter to Senator Stabenow
  • eviCore - Update on APTA Michigan Strategies and Related Actions
  • APTA Michigan Letter to BCBSM June 30, 2017
  • APTA Michigan Letter to Priority Health June 6, 2017
  • APTA Michigan Letter to BCBSM May 12, 2017
  • BCBSM Minutes from Meeting March 13, 2017
  • APTA Michigan Letter to BCBSM March 13, 2017
  • APTA Michigan Letter to BCBSM October 17, 2016
  • APTA Michigan Letter to BCBSM June 23, 2016

Important Payment Resources

Medicare Resources

Medicare Claims Update

Fiscal Intermediaries (FI's) process Medicare claims for services provided in facilities such as Hospitals, Skilled Nursing Facilities (SNF's), Outpatient Rehabilitation Facilities (ORF's), and Comprehensive Outpatient Rehabilitation Facilities (CORF's). These FI's have web sites that provide a vast amount of information regarding Medicare coverage and billing. Your billing office will know the identity of the FI that processes your claims.

United Government Services (UGS) is the largest Medicare Part A Intermediary processing over 30 million claims nationwide each year. UGS serves customers in (insert association's state MI or WI) as well as many other states. The following UGS website contains valuable information that includes: the publication "Physical Therapy, Occupational Therapy and Speech-Language Pathology Outpatient Services Educational Update", Frequently Asked Questions (FAQs), Local Medical Review Policies, Medicare Memos (the monthly newsletter from UGS), links to Centers for Medicare and Medicaid (CMS) websites and more.

Medicare Links

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