A new CPT® code for cognitive function intervention (97127) takes effect January 1, 2018, replacing CPT code 97532. While private insurance and Medicaid may cover this code, The Centers for Medicare & Medicaid Services (CMS) has created a separate code for use in Medicare.
Effective January 1, 2018, OT practitioners and others can no longer bill CPT code 97532 for cognitive skills development to any payer, as it is no longer in the CPT system. Practitioners must use a new CPT code, 97127, which describes cognitive function interventions. However, Medicare will not pay for this code but has created a “G-code” for cognitive interventions that may be paid under Medicare. Medicare’s definition of this G-code mirrors the former CPT descriptor and is a 15-minute code.
The new CPT code 97127 has a broader definition and was developed to report therapeutic interventions that reflect the concept of cognitive function. AOTA worked with other concerned associations, including the American Speech-Language-Hearing Association (ASHA) and the American Psychological Association (APA) to develop the code’s more contemporary language through the American Medical Association (AMA), which owns and governs the CPT code development process. Most importantly, the new CPT code (97127) is not a 15-minute code; it is designed as a “per session,” or untimed code. But because of concerns about potential misuse of an untimed code, CMS in the Fee Schedule for 2018 is not recognizing the new CPT code and has established a separate code that Medicare will require, G0515.
How CPT 97127 (Cognitive Function) differs from CPT 97532 (Cognitive Skills)
The new code, CPT 97127, descriptor reads:
“Therapeutic interventions that focus on cognitive function (e.g., attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing and sequencing tasks), direct (one-on-one) patient contact.”
The previous code, 97532, was limited to the development of cognitive skills to improve attention, memory, and problem solving. New CPT 97127 expands the range of the code to include areas that are within the scope of and frequently addressed by occupational therapy: executive function, reasoning, pragmatic functioning, and the use of compensatory strategies for managing the performance of activities.
What is in Medicare’s New G0515 Code?
In the final 2018 Medicare Physician Fee Schedule, CMS stated that it will not accept CPT 97127 under Medicare. As noted above, CMS has concerns about the untimed aspect of the new code; Medicare will pay G0515 in 15-minute increments as it pays most other Physical Medicine and Rehabilitation CPT codes familiar to OT practitioners. G0515 matches the old CPT code 97532 in terms of payment, value, descriptor language, and timed status as a 15-minute code. It reads:
Development of cognitive skills to improve attention, memory (includes compensatory training), direct one-on-one patient contact, each 15 minutes.
G0515 should be used in the same way as 97532 had been used prior to its deletion.
OT practitioners are urged to check with non-Medicare payers (e.g., Medicaid, Medicare Advantage [Part C], commercial payers) to verify which code (97127 or G0515) they will reimburse. OT practitioners should also carefully review payer policies and reimbursement rates for the new 97127 as it is for only session or unit per day.
Contact AOTA Regulatory Affairs at firstname.lastname@example.org for more information or to report problems with either the new code or the Medicare G-code.