Advocacy success: AOTA reverses Medicaid NCCI billing edit

The National Correct Coding Initiative (NCCI) was created by the Centers for Medicare and Medicaid Services (CMS) to promote accurate coding and reduce improper payments by establishing billing and coding rules. These rules, called procedure-to-procedure (PTP) edits, identify Current Procedural Technology (CPT®) codes that cannot be billed together on the same day or that can only be billed together when additional billing information is provided to signify that the services were separate and distinct from each other. While NCCI PTP edits most often apply to Medicare Part B services, state Medicaid agencies, and third-party commercial payers also utilize NCCI edits. These other payers may modify the edits to meet their own programmatic needs, which may cause confusion during the coding and billing process regarding whether code pairs are allowed and when to use a billing modifier. With so many scenarios where these edits can be applied, it can be challenging for occupational therapy practitioners (OTPs) to know how to ensure accurate reimbursement for the occupational therapy services provided.

AOTA Partners with Members for Payment Advocacy

The AOTA Regulatory Affairs staff team closely monitors Medicare, Medicare Advantage, Medicaid, and commercial insurance plans for policy changes, such as NCCI coding edits that impact occupational therapy reimbursement. With regional commercial plans and state-specific Medicaid reimbursement, however, policies can vary widely, so the Regulatory Affairs team also relies on AOTA members and state associations to alert us to upcoming policy changes that will impact the provision of OT services and priorities for payment advocacy. Thanks to one member’s outreach, AOTA was recently able to address a problematic coding edit present in the national Medicaid NCCI edit table when CPT code 97530 (therapeutic activities) is billed by occupational therapy practitioners on the same day as CPT code 97533 (sensory integration). While the Medicaid NCCI edit rules do allow this code pair to be billed together with the use of a modifier to identify the services are separate and distinct from each other, the AOTA member was experiencing significant administrative burden in determining when to appropriately append the modifier on claims because the edit, present on the Medicaid NCCI edit table, was no longer being utilized by Medicare, which the member also bills for her services. Even when the modifier was correctly appended to claims with this code pairing, the member was experiencing delays with payment from Medicaid payers due to increased payer requests for medical records to support modifier use prior to paying the claims.

AOTA Advocacy Success

The Regulatory Affairs team advocated with the Centers for Medicare and Medicaid Services (CMS) to remove the edit from the Medicaid NCCI table to allow 97530 and 97533 to be billed on the same date--without requiring additional modifiers or documentation for reimbursement.

As a result, CMS reviewed the request and agreed to remove this edit from the national Medicaid edit table, effective with the April 2023 NCCI quarterly update.

This AOTA Medicaid payment policy win will help reduce the administrative burden for our private practice members billing Medicaid and managed care Medicaid payers who utilize the national Medicaid edit table for coding decisions, reduce confusion with billing by improving alignment between Medicare and Medicaid payment policies for OT services, and open the door for advocacy with other payers who still have these edits in place.

AOTA is advocating for occupational therapy reimbursement every day, but we can’t do it without our members being engaged and reaching out to share their ideas and challenges. This Medicaid advocacy win was achieved through AOTA’s collaboration with its members and is just one example of the power member experiences can have on payment policy.

AOTA’s Regulatory Affairs Department provides advocacy and member support on a variety of payer policy, regulatory, and coding topics. For assistance, please contact regulatory@aota.org.