New Year, New Changes? That’s what’s going to happen this 2019 for Physical Therapists, Speech Language Therapists, and Occupational Therapists.
As the medical billing service, we’re writing down things you need to know about the significant changes in physical therapy billing and other medical billing services for therapists in 2019.

Here’s why you should choose the right physical therapy billing company :

MEDICARE CAP FOR 2019

For this year, the Medicare Cap for Physical Therapy, Occupational Therapy Billing Services and Speech-Language Pathology services has reached $2,040. Since the hard cap has been repealed, the soft therapy cap have been imposed so that the therapists must apply for the KX modifier once the cap has been met to fully receive payment for “medically necessary services” — a key phrase that is important on their notes, in addition to a complete set of documents for additional services past the cap.   Medical Review Cap remained constant at $3000. If therapy services have been provided past the #3k cap, a Medicare contractor may review the medical records to check for medical necessity.   The annual dollar limit for the caps reset on January 1st of 2019, so the KX modifier should not be used on claims until the soft cap has been reached. Improper usage of the KX modifiers may be triggered and audited, thus, correct usage must be complied.

2019 CPT Code Changes

Here are the several CPT code changes that go into effect on January 1, 2019.

New Untimed Codes for OT and SLP

96112 – Developmental test by qualified healthcare professional; first hour 96113 – Developmental test by qualified healthcare professional; each additional 30 min 96121 – Neurobehavioral status exam by a qualified healthcare professional; each additional hour 96130 – Psychological test by qualified healthcare professional; first hour 96131 – Psychological test by a qualified healthcare professional; each additional hour 96132 – Neuropsychological eval by qualified healthcare professional; first hour 96133 – Neuropsychological eval by qualified healthcare professional; each additional hour 96136 – Psychological/neuropsychological test by qualified healthcare professional; first 30 min 96137 – Psychological/neuropsychological test by qualified healthcare professional; each additional 30 min 96146 – Psychological/neuropsychological test by standard instrument via electronic platform/auto result  

New Timed Codes for Occupational Therapy and SLP

7151 – Behavior ID Assessment by qualified healthcare professional; each 15 minutes 97155 – Adaptive behavior treatment w/ protocol mod by a qualified healthcare professional; each 15 minutes 97156 – Family adapt behavior treatment by a qualified healthcare professional (with or without patient present); each 15 minutes 97157 – Multi-family group adapt behavior treatment by a qualified healthcare professional (without patient present); each 15 minutes 97158 – Group adaptive behavior treatment w/ protocol mod by a qualified healthcare professional (multiple patients); each 15 minutes

Retired Codes

96111 – Developmental Testing extended, with interpretation and report 64550 – Tens unit application

Functional Limitation Reporting

Physical Therapists, Occupational Therapists, and Speech Language Therapists need NOT to have complete Functional Limitation Reporting for Medicare Part B and Railroad Medicare beneficiaries, however, commercial payers like Medicare Advantage plans and Worker’s Compensation plans, that use the Functional Limitation Reporting system are not affected by this significant change, yet, may still require FLR codes.   Six of the FLR codes (G8980, G8983, G8986, G8989, G8992, and G8995) can be used for MIPS reporting so they may continue to be used if you participate in the MIPS program.

Medicare Fee Schedule and Therapy Assistants

Here’s what you need to know about the fees starting in 2022: Medicare will pay 85% of the fee schedule for PTAs, OTAs, and COTAs when they perform 10% or more of any service. New modifiers CQ and CO will be used to report services reported by the PTA OTA and COTA.   Although it will take effect for a few years from now on, it will directly impact the bottom-line of many practices and will require new reporting policies, and procedures so it is best to start preparing and planning now for this another significant change.