1. Schaum, Kathleen D. MS

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Physical and occupational therapists are vital members of the multidisciplinary wound/ulcer management team. Like other disciplines, they have some confusing reimbursement regulations that can generate many questions. Since this new decade began, therapists have submitted many questions to this author. Therefore, this month's column will address the frequently asked questions submitted so far this year.


Q: What is the difference between a Therapy Cap and a Therapy -KX Modifier Threshold?


A: Therapy Caps were "on-again/off-again" limitations to the amount of Part B-covered therapy services that Medicare was willing to cover per beneficiary per year. Therapy Caps were first initiated by the Balanced Budget Act of 1997. Between 1997 and 2018, they were placed on moratorium and reimplemented several times. In years when the Therapy Caps were active, therapists found it difficult to get paid if the volume of services they provided to a specific Medicare beneficiary exceeded that year's Therapy Cap. These unpopular and unpredictable limitations were finally repealed by the Bipartisan Budget Act of 2018.


However, the Bipartisan Budget Act replaced the Therapy Caps with designated therapy thresholds. If a Medicare beneficiary requires therapy services that exceed the designated therapy threshold, therapists are required to confirm (in their medical record documentation) the medical necessity and justification for the additional therapy service. All claims submitted for the therapy services above the designated therapy threshold must have a -KX modifier appended to the code for each service or the claim will be denied. Therefore, these amounts are now called Therapy -KX Modifier Thresholds: physical therapy (PT) and speech language pathology (SLP) services share one Therapy -KX Modifier Threshold, whereas occupational therapy (OT) services have a separate Threshold.


Q: Do the Therapy -KX Modifier Threshold amounts vary from year to year?


A: Yes, they are updated each year according to the Medicare Economic Index. In 2020 the combined PT/SLP Therapy -KX Modifier Threshold amount increased to $2,080 from $2,040 in 2019. Similarly, the OT Therapy -KX Modifier Threshold amount increased to $2,080 from $2,040 in 2019.


Q: To which settings and providers do the Therapy -KX Modifier Thresholds apply?


A: The Therapy -KX Modifier Thresholds apply to all Part B outpatient therapy settings and providers:


* Therapists in private practice


* Offices of physicians and certain nonphysician practitioners


* Part B skilled nursing facilities


* Home health agencies


* Rehabilitation agencies (also known as outpatient rehabilitation facilities)


* Comprehensive outpatient rehabilitation facilities


* Hospital outpatient provider-based departments


* Critical access hospitals



Q: Is the Targeted Medical Review Threshold something different than the Therapy -KX Modifier Threshold?


A: Yes, the Targeted Medical Review Threshold is the annual per beneficiary therapy services amount that may trigger a medical review by a Medicare contractor. The CMS announced that contractors will select their medical review targets based on criteria such as a high percentage of patients receiving therapy beyond the Targeted Medical Review Threshold as compared with peers. The Targeted Medical Review Threshold amount will remain at $3,000 for PT/SLP services combined and at $3,000 for OT services until calendar year 2028, when it will be updated according to the Medicare Economic Index.


Q: I heard that there are new therapy modifiers. Do the new modifiers replace the therapy modifiers -GN, -GO, and -GP that therapists currently use to identify their work?


A: Yes, there are new therapy modifiers, but they do not replace the modifiers that are used by therapists who provide services under a therapy plan of care. These therapy modifiers are still expected on Medicare claims:


-GN: Services delivered under an outpatient SLP plan of care


-GO: Services delivered under an outpatient OT plan of care


-GP: Services delivered under an outpatient PT plan of care



However, effective January 1, 2020, the two new modifiers must be used when therapy assistants perform more than 10% of the service:


-CQ: Outpatient PT services furnished in whole or in part by a PT assistant (PTA)


-CO: Outpatient OT services furnished in whole or in part by an OT assistant (OTA)



The CMS identified certain situations when the new therapy assistant modifiers apply:


* Therapeutic portions of outpatient therapy services furnished by PTAs/OTAs, as opposed to administrative or other nontherapeutic services that can be performed by others without the education and training of OTAs and PTAs


* Services wholly furnished by PTAs or OTAs without physical or occupational therapists


* Evaluative services that are furnished in part by PTAs/OTAs (keeping in mind that PTAs/OTAs are not recognized to wholly furnish PT and OT evaluation or reevaluations)



In addition, the CMS identified some situations when the new therapy assistant modifiers do not apply:


* When PTAs/OTAs furnish services that can be done by a technician or aide who does not have the training and education of a PTA/OTA


* When therapists exclusively furnish services without the involvement of PTAs/OTAs



Documenting and keeping track of an assistant's time are a bit tricky and will most likely require the refinement of your documentation, coding, and billing processes. Therefore, therapists and therapy assistants should carefully review pages 62702-62709 of the 2020 Medicare Physician Fee Schedule (MPFS) Final Rule: The entire therapy revenue cycle team should make the necessary process refinements now; do not wait until 2020 when Medicare will apply a statutorily required payment reduction for services reported with the -CQ and -CO modifiers.


Q: We have been reporting the functional limitation G-codes on our therapy claims submitted to Medicare. Therapists who work in neighboring facilities informed us that the G-codes are no longer required. Is that true?


A: Yes, it is true. Actually, the G-codes have not been required since dates of service on or after January 1, 2019. Further, the 42 functional limitation G-codes were deleted for dates of service after December 31, 2019.


Q: Our hospital outpatient wound/ulcer management provider-based department is currently billing Medicare for lymphedema services provided by a nurse. I think the codes for the four components of complete decongestive therapy are designated "always therapy" codes by Medicare. Am I correct? If so, how can I prove this fact?


A: You are correct. Medicare will only pay therapists to perform lymphedema therapy. You can prove this fact by referring to the 2020 Therapy Code List and Dispositions at There you will see that 97016, 97110, 97140, and 97535 are assigned therapy disposition code 5. The definition of that disposition code states: "These codes are 'always therapy' services, regardless of who performs them. These codes always require a therapy modifier -GP, -GO, or -GN to indicate that they're furnished under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively."


Q: Our outpatient physical therapists would like to accommodate their patients who prefer disposable negative-pressure wound therapy (dNPWT) rather than the larger NPWT durable medical equipment. However, our coders and billers tell us that Medicare will only pay PTs to apply NPWT durable medical equipment. This does not make sense to our therapy team. Is it really true?


A: The answer begins with the bad news and ends with good news.


First the bad news: When the two new dNPWT codes (97607 and 97608) were first released, Medicare published both outpatient prospective payment system allowable rates and similar home health agency allowable rates for supplying and applying new dNPWT pumps. Unfortunately, Medicare did not establish rates for the dNPWT codes on the MPFS that applies to the work of physicians, other qualified healthcare professionals, and therapists. Therefore, your coders were correct. In years prior to 2020, outpatient therapists were not paid by Medicare for providing dNPWT to their patients.


Now the good news: Effective January 1, 2020, the CMS has published allowable rates for 97607 and 97608 on the MPFS. Now at visits when a therapist supplies and applies a new dNPWT pump to the patient, the outpatient therapist can code and receive Medicare payment for either 97607 or 97608. If the procedure is covered for that patient, the 2020 MPFS national average allowable payment rate is $342.85 for 97607 and $343.93 for 97608. Therefore, therapists should (1) share this good news with their coders and billers, (2) correctly set their charges for 97607 and 97608 to include the charge for the new dNPWT pump and the work to apply it in their charging systems, and (3) educate their team that they should only report the dNPWT codes for encounters when they supply and apply a new dNPWT pump to a Medicare beneficiary who qualifies for dNPWT.


You may be interested to know that the new 2020 MPFS national average allowable payment rates for 97607 and 97608 are greater than the 2020 outpatient prospective payment system national average allowable payment rate, which is $319.51 for each code.