Eli's Rehab Report

CFA has temporarily suspended version 6.3 of the national Correct Coding Initiative (CCI) edits that bundled 66 evaluation and management (E/M) services to 34 physical medicine and rehabilitation procedural codes. The announcement was made on Jan. 26, 2001, and the suspension is retroactive to Oct. 30, 2000, the effective date of the 6.3 edits. It also includes any edit pairs that were continued in version 7.0, effective through March 31, 2001. HCFA is reviewing the edits, and a number of them may be re-implemented no earlier than July 1, 2001.

A HCFA spokesperson said the agency would not comment on its reason for suspending the edits. Most significant among the 6.3 edits was the bundling of E/M services with diagnostic procedures a decision that took many physicians and coders by surprise, says Barbara Cobuzzi, CPC, CHBME, president of Cash Flow Solutions Inc., a physician billing firm in Lakewood, N.J. The changes were not adequately publicized and placed a financial burden on physicians who were suddenly receiving denials for previously covered procedures, Cobuzzi says.

The following physical medicine codes are no longer bundled with E/M services:

97003-97004 (occupational therapy evaluation and re-evaluation)

CPT 97012 CPT 97530 (these 26 codes include such modalities as electrical stimulation, therapeutic procedures, manual therapy and therapeutic activities)

97535-97545 (ADL training, community/work reintegration training, wheelchair management training and work conditioning)

97703-97750 (orthotic/prosthetic checkout, physical performance test)

Physical medicine practices are encouraged to review denials received on the inclusive codes and to resubmit applicable claims to their carriers (carriers will not automatically be reprocessing denied claims). Any denied E/M services meeting the criteria of significant and separately identifiable should be resubmitted, and despite the suspended edits, modifier -25 should still be appended to the E/M service when submitting these claims together because it is considered correct coding to use modifier -25 to prove that the services were significant and separately identifiable.

HCFAs edit suspension does not affect edits involving E/M services that were implemented before Oct. 30, 2000.