AOTA Advocacy Success: Evaluation Payments Expected to Rise as CMS Corrects Error


Updated: 3/8/2017

Rates for payment of occupational therapy evaluation codes will be going up for 2017. AOTA met with officials at the Centers for Medicare & Medicaid Services (CMS) March 1 to present information and research to correct what AOTA believed was an error in the Final Rule setting payment for CPT® codes in Medicare for 2017. The meeting was the culmination of months of effort to correct payment levels for the evaluation codes. AOTA reported in January after hearing from members that the reimbursement rate for the OT Evaluation codes (97165, 97166, and 97167) and the Re-evaluation code (97168) decreased in 2017 from the 2016 rate. AOTA staff, volunteers, and consultants reviewed the final proposed rate and consulted with CMS and the American Medical Association (AMA), which runs the process to determine code payment values. After this research AOTA could find no rationale for the significant reimbursement decreases evidenced in CMS’ final Part B payment rule. AOTA reviewed the Work and Practice Expense values that AOTA presented to the AMA’s Specialty Society Relative Value Scale Update Committee (RUC) in October 2015 as part of the code change process. Armed with that data, AOTA requested a meeting with agency officials to strenuously argue against this reduction.

CMS explained in the meeting that there was a computational error in determining the Practice Expense (PE) relative value unit (RVU) for the OT Evaluation code and Reevaluation code that occurred between the publication of the Medicare Fee Schedule Proposed Rule in June 2016 and the Final Rule published in November 2016. The problem on the CMS end was a technical error; the Practice Expense component of the calculation was incorrect.  

Dr. Katie Jordan, Professor of Clinical Occupational Therapy at the USC Mrs. T. H. Chan Division Occupational Science and Occupational Therapy, and AOTA’s alternate representative to the RUC, was instrumental in collecting and presenting data successfully to CMS. “We were elated to get a positive response from CMS made possible by AOTA staff and volunteers collaborating to take quick and direct action,” Dr. Jordan noted.

Next steps: The Practice Expense RVU has already been corrected in the CMS April Quarterly Update Transmittal #3719 and the new information has been sent to the Medicare Administrative Contractors (MACs). CMS has also released a MLN Matters article on the updates. AOTA anticipates MACs will post the updated increased payment rates soon. These corrected rates will be retroactive to January 1, 2017. In addition, CMS informed AOTA that a Fee Schedule Correction Notice will be issued in the Federal Register soon. 

AOTA’s vigilance and advocacy brought CMS to correct its error. It is expected that this important correction will lead to a reimbursement increase in most, if not all, MAC regions.

AOTA asks that you check your MAC website’s fee schedule calculator periodically to confirm that the reimbursement increase has taken effect in your region. Advise your billing department to be aware of the change going forward and the retroactive correction. Also, stay tuned to AOTA’s Coding and Billing webpage for updates, as well as new resources on how to bill the OT evaluation codes.