Cigna recently announced 2 new policies that included a 4 unit per visit limitation and a 15% payment differential cut for services provided by an OTA or PTA effective October 15th with TX, KY, CO, and OH starting on November 1st.
APTA and AOTA met with Cigna to highlight the adverse impacts of the proposed differential policy and to request mitigation. Despite the evidence provided, Cigna made the decision to move forward with the policy in its original form with a minor change. Cigna plans to add new language indicating providers are required to abide CMS billing guidelines.
The new Cigna policies are found here and described below: 873827_ExternalHCP_Template2014_V2 (mercyoptions.net) and CHCP – Resources – Policy Updates July 2022 (cigna.com).
PTA differential: Modifiers CO and CQ reimbursement reduction for physical or occupational therapy assistant services Reimbursement for claims submitted with modifiers CO and CQ for services provided by a physical therapy (PT) or occupational therapy (OT) assistant will be reduced by 15 percent. This update more closely aligns with industry standards, including the CMS National Physician Fee Schedule, which reimburses these services at 85 percent. We will update the Health Care Common Procedure Coding System (HCPCS) National Level II Modifiers reimbursement policy to reflect this change. This update is effective for dates of service on or after October 15, 2022 (in all states except TX, KY, CO, and OH where it starts on November 1st).
4 unit per visit limit: Physical therapy, occupational therapy, and chiropractic claims for greater than four units (60 minutes) of timed service. The portion of a physical therapy (PT), occupational therapy (OT), or chiropractic claim that is greater than four units (60 minutes) of timed, short-term rehabilitation services per patient, per day, per provider will be denied as being not medically necessary. We will update the Omnibus Codes (0504) medical coverage policy to reflect this change. This update is effective for dates of service on or after October 15, 2022 (except in TX, KY, CO, and OH where it starts on November 1st).
Other available details:
- Cigna direct agreements including outpatient hospital facilities are impacted.
- Cigna out of network providers are impacted.
- There are no plan exclusions.
- ASH (American Specialty Health) will not implement the PTA/OTA modifiers and the four unit per visit limitation of timed codes is already built into the ASH utilization review process.
- There is an exception process in place based on medical necessity review with appeal rights for the 4 unit per visit limitation.
- ASH notified providers on 8/1/22.
- Cigna notified providers around 8/3/22.
APTA PTA differential and CQ modifier resources are found here:
Thank you for your advocacy.