Practice strives to provide tools and resources to support the safe and effective provision of physical therapy services in all settings.
Medicare does not pay for orthoses or supports primarily made of elastic or other stretchable materials such as neoprene, spandex, elastane, or lycra. Previous coding policy excepted code L3923 from this policy if an adjustable insert was included and used to custom fit the support for the patient if the code was submitted with a CG modifier. New guidance indicates the CG modifier has been discontinued with upper extremity orthoses. Hand-finger neoprene, elastic or other soft material supports requiring custom fitting of an incorporated metal or thermoplastic support should be coded as L3923 without a CG modifier. The finger modifiers still apply. If the HFO is composed of the fabrics listed above and does not contain a moldable support, it should be coded A4467: “Belt, strap, sleeve, garment, or covering, any type” and is not covered by Medicare.
For more information, see: https://med.noridianmedicare.com/web/jddme/search-result/-/view/2230703/hand-finger-orthoses-l3923-use-of-cg-modifier.
Medicare orthosis suppliers must renew their supplier number every 3 years. One of the requirements for a participating supplier is maintaining $300,000 general liability insurance policy with the supplier enrollment contractor as the certificate holder. The enrollment contractors changed in November of 2022 so renewing suppliers will have to change their liability policies to reflect the new contractor as their insurance certificate holder. A map showing the new contractor locations can be found here: https://www.cgsmedicare.com/jc/pubs/news/2022/11/cope3059.html.
HHS has issued a revised “Frequently Asked Questions” document for the Good Faith Estimate Requirements for cash based practices. The updated document can be accessed here: Good Faith Estimate FAQ's
New place of service codes were published In January of 2022:
02: Telehealth Provided in location other than patient’s home (revised)
10: Telehealth Provided in the Patient’s Home (New)
Medicare contractors will not begin processing them until April 4, 2022, but some private insurers have already implemented the codes. Check with individual payers when billing for telehealth services. For more information: Telehealth code changes
The department of HHS instituted regulations designed to improve patients’ access to electronic health information in 2021. A new report details the 299 complaints received by HHS since the start of the program and 211 targeted health care providers. Make sure your practice is compliant with the rules by reviewing the: APTA Info Blocking Advisory.
On 1/13/22 CMS issued updates to the master list of DMEPOS items that could be moved to the list of items requiring either a Face to Face order prior to delivery or prior authorization. Some spinal and knee orthoses were added to the prior authorization list, but no upper extremity orthoses. For the required Face to Face encounter and written order prior to delivery list the only UE orthosis is: L3960, SEWHO, Airplane design, Prefabricated. There are 2 lumbar-sacral orthoses and 3 knee orthoses that were also added. For complete information see: Medicare Program DMEPOS list updates.
The recently enacted Omnibus legislation authorizes current temporary telehealth flexibilities in all practice settings until December 31, 2024.
CMS has published multi-lingual telehealth resources for patients in 6 additional languages including: Arabic, Chinese, Creole, Haitian, Korean, Russian, and Vietnamese. These resources are available at CMS Telehealth Resources.
PTA Differential
Beginning in 2022, services provided “in whole or part” by PTA’s will be reimbursed at 85% of the PFS.
IN part is defined as >10% of the 15” code performed solely by PTA (not PT and PTA together). If the PT and the PTA each perform billable time for the same CPT code, the services can be reported on separate claim lines with the appropriate modifier (CQ for PTA and GP for PT).
Due to the expiration of the PHE on May 11, 2023, PTAs must receive direct supervision in outpatient settings beginning in 2024.
CMS made permanent changes proposed during the PHE permitting PTs to delegate maintenance therapy in part B settings to their supervised PTA.
APTA has assembled Medicaid physical therapy coverage and fee schedule data from all states creating the APTA State Medicaid Payment Rate Guide. This tool allows members to compare coverage and reimbursement rates within and between states and will be a valuable tool for fair payment advocacy. For more information: Medicaid State Payment.
APTA and the Private Practice Section have partnered to develop resources and tools to help PT’s address the overuse of prior authorization and utilization management barriers to medically necessary care. This new set of resources includes advice reversing payment denials, dealing with prior authorizations, template letters for patients and providers to legislators, insurance commissioners, employers and state Medicaid offices. This “members only” benefit can be accessed here: State Payer Resources
UnitedHealth has reversed some changes to its Commercial and individual exchange plansf.
UHC will begin removing prior authorization requirements for some procedures and equipment beginning 9/1/23 depending on the UHC plan. See the UHC link above for complete details.
Humana has contracted with Cohere, a UMN, to handle authorization of therapy services including PT, OT and SLP for all commercial and Medicare Advantage plans. In meetings with APTA staff, Cohere representatives provided some information specific upper extremity conditions and orthoses.
Please contact Marsha at [email protected] to report coverage denials for UE rehab or orthoses.
Iowa physical therapists are now eligible to order imaging, bringing the total to 9 states.