KMAP BULLETIN: Update to Cognitive Therapy Code Change on the BI Waiver

Date: 02/08/24

KMAP GENERAL BULLETIN 24030 (PDF)External Link

In 2020, following the National Correct Coding Initiative's (NCCI’s) guidance, the Centers for Medicare and Medicaid Services (CMS) eliminated HCPCS Level II G-codes, including the Cognitive Therapy code used in the Brain Injury (BI) waiver program. This led to the adoption of two new Current Procedural Terminology (CPT) codes: 97129 for the initial 15 minutes of therapy and 97130 for each subsequent 15-minute unit. However, with the implementation of the Electronic Visit Verification (EVV) system, providers would have been required to clock in and out for the first 15 minutes before clocking in again for the subsequent units. With the intention to streamline the process and reduce the need for frequent clock-ins and outs associated with the previous codes, the Kansas Department of Aging and Disability (KDADS) and Kansas Department of Health and Environment (KDHE) identified two new, alternative CPT codes that align more closely with Cognitive Therapy services: 97535 and 97357. These two codes replace 97129 and 97130, effective February 1, 2024.

Considerations:

  1. Medically Unlikely Edits (MUE): Both new codes have MUEs associated with them. MUEs are rules set by CMS and used in healthcare billing to prevent unrealistic or excessive billing. They set limits on how often a medical service can be billed for a patient in one day, based on what is usually safe and reasonable in medical practice.
  2. New CPT Codes and associated MUE Limits:
    1. CPT Code 97535 (8 units/2 hours MUE daily limit): This code represents self-care/home management training. This includes activities of daily living (ADL) training, compensatory training, going over safety procedures/instructions, meal preparation, and use of assistive technology devices or adaptive equipment, direct one-on-one contact by the provider, each  unit = 15 minutes.
    2. CPT Code 97357 (6 units/1.5 hours MUE daily limit): This code represents community/work reintegration training (e.g., shopping, transportation, money management, avocational activities and/or work environment/modification analysis, use of assistive technology device/adaptive equipment), direct one-toone contact by the provider, each unit = 15 minutes. 
  3. Compliance with MUE Limits and Service Definitions: It is important to note that although there are currently no exceptions to the MUE limits and definitions identified by CMS for these two new codes, KDADS has submitted a request to CMS seeking retroactive exemptions to the MUE limits, effective February 1, 2024. In the meantime, KDADS, Providers, and Managed Care Organizations (MCOs) are expected to collaborate closely to ensure person-centered outcomes as claims for dates of service (DOS) where the total units of services provided exceed the MUE daily limit will be denied. Please note that despite daily MUE restrictions, the benefit limit for combined therapies under the BI waiver remains capped at 3,120 units annually and MCOs will continue to authorize waiver services monthly.
  4. Prior Authorization Adjustments: MCOs have proactively updated prior authorizations in preparation for this change. Providers may need to revise initial Person-Centered Service Plans (PCSP) or prior authorizations to align with the new codes and their specific unit limits. Moving forward, the PCSP meeting will be the driver in determining the appropriate allocation of services based on the individual's unique needs and circumstances, ensuring that the chosen CPT codes and their unit limits are effectively utilized to maximize therapeutic benefits within the parameters of the BI waiver program.
  5. Ongoing Communication: Providers are encouraged to maintain open lines of communication with Care Coordinators for any necessary adjustments. KDADS and the MCOs are committed to facilitating smooth transitions. KDADS will continue to work with MCOs and other impacted stakeholders, both collectively and individually, to monitor the impact and outcomes of these changes.

We understand the impact this may have and are diligently working towards a more permanent solution. We appreciate your cooperation and commitment to providing quality care within the updated regulatory framework.