New Cognitive Therapy Code Debuts in 2018 Coding changes also include new modifiers for habilitative and rehabilitative services. Policy Analysis
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Policy Analysis  |   October 01, 2017
New Cognitive Therapy Code Debuts in 2018
Author Notes
  • Neela Swanson is ASHA’s director of health care coding policy. nswanson@asha.org
    Neela Swanson is ASHA’s director of health care coding policy. nswanson@asha.org×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   October 01, 2017
New Cognitive Therapy Code Debuts in 2018
The ASHA Leader, October 2017, Vol. 22, 22-24. doi:10.1044/leader.PA1.22102017.22
The ASHA Leader, October 2017, Vol. 22, 22-24. doi:10.1044/leader.PA1.22102017.22
Speech-language pathologists should prepare for significant changes to Current Procedural Terminology (CPT® American Medical Association) coding for cognitive therapy services, including a shift from the current 15-minute unit structure to a per-day untimed code.
However, Medicare may not accept the new code in its fee schedule, and SLPs may need to use different billing codes depending on the patient’s payer.
Audiologists and SLPs also may need to use new modifiers that indicate whether services provided are habilitative or rehabilitative if they are billing treatment to health insurance plans that are compliant with the Affordable Care Act of 2010 (ACA).
There are no major changes to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code set for audiology and speech-language pathology services for 2018, and CPT coding for audiology services also will not change.
Cognitive therapy coding
A new CPT code for cognitive function intervention takes effect Jan. 1, 2018, replacing current CPT code 97532: “Development of cognitive skills to improve attention, memory, problem-solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes.”
The new code, CPT 97127, is defined as:
“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.”
CPT 97127 may be reported only once per day—regardless of the length of the session—because it is an untimed code, similar to most CPT codes used to report speech-language and swallowing services (for example, CPT code 92526 for treatment of swallowing and feeding disorders).
The American Medical Association, which develops the CPT code set to describe services provided by physicians and other allied health professions, changed the cognitive therapy code in response to CMS pressure. CMS urged the revision of the entire physical medicine and rehabilitation family of codes (the 97000 series)—which includes 97532—from timed to untimed codes. CMS was concerned about overuse of the codes and the potential for abuse of the 15-minute timed codes.

A new CPT code for cognitive function intervention takes effect Jan. 1, 2018, replacing current CPT code 97532.

SLPs and psychologists—and, to a lesser degree, occupational therapists—are the primary billers of 97532. ASHA worked with the American Psychological Association and the American Occupational Therapy Association to develop the new code for cognitive function intervention.
In the proposed 2018 Medicare Physician Fee Schedule released in July, however, CMS indicates it will not accept CPT 97127 for Medicare payment, giving the impression that CMS has reversed its opinion on untimed codes. Instead, CMS will replace the new code with a Medicare-specific G-code that exactly duplicates the current 97532 in description and in payment. Medicare develops G-codes for specific programmatic needs that can’t be met with existing codes, such as the G-codes used for functional outcomes reporting.
CMS’ primary concern regarding the new untimed code is high use of cognitive therapy services in facility-based settings (for example, skilled nursing facilities), and how different providers (occupational therapists, physical therapists, SLPs and psychologists) bill for cognitive therapy for widely different amounts of times in both outpatient and facility-based settings.
Should the CMS proposal take effect in 2018, use of the new G-code (which would be specific to the Medicare program) could be confusing for SLPs who bill Medicare and other non-Medicare payers. 97127 will still exist in the 2018 CPT code set, so clinicians may find themselves reporting cognitive therapy services differently, depending on the payer.
For payers who do accept the new code, clinicians should carefully review the payment rate for 97127 to ensure that payers are not reimbursing it at the same rate as a single 15-minute unit of 97532. Contact ASHA at reimbursement@asha.org if a payer is not appropriately implementing the new cognitive therapy code as an untimed service.
ASHA and other stakeholders met with CMS officials in August and have submitted extensive comments expressing concerns and outlining potential solutions to provide the best possible outcome for SLPs. CMS will publish its decision in early November when the agency finalizes the 2018 Medicare Physician Fee Schedule.

For payers who do accept the new code, clinicians should carefully review the payment rate for the new code to ensure that payers are not reimbursing it at the same rate as a single 15-minute unit of 97532.

New modifiers
Audiologists and SLPs who provide treatment services such as aural rehabilitation or speech-language therapy may already identify habilitative services on claims to comply with an ACA mandate that took effect in January. The mandate requires all individual and small-group non-grandfathered health plans to have separate visit limits for habilitative and rehabilitative services. To appropriately administer the separate visit limits, clinicians need to identify whether a provided service is habilitative or rehabilitative.
In 2017, the most common method for tracking habilitative services has been through the –SZ modifier, which is added to the corresponding CPT code on the claim form. However, there is no mechanism for clinicians to indicate a rehabilitative service, leaving health insurance plans to make assumptions about the nature of the services when a modifier is not included.
To alleviate the potential for confusion, Humana, a private health insurance company, developed new CPT modifiers to delineate habilitative and rehabilitative services. ASHA worked with Humana to ensure the modifiers accurately reflect the services of audiologists and SLPs.
Two new modifiers and descriptions will be listed in Appendix A of the 2018 CPT code book and could be added to the appropriate CPT codes on claims submitted to ACA-compliant health insurance plans:
  • 96, habilitative services: “When a service or procedure that may be either habilitative or rehabilitative in nature is provided for habilitative purposes, the physician or other qualified health care professional may add modifier 96 to the service or procedure code to indicate that the service or procedure provided was a habilitative service. Habilitative services help an individual learn skills and functioning for daily living that the individual has not yet developed, and then keep and/or improve those learned skills. Habilitative services also help an individual keep, learn or improve skills and functioning for daily living.

  • 97, rehabilitative services: “When a service or procedure that may be either habilitative or rehabilitative in nature is provided for rehabilitative purposes, the physician or other qualified health care professional may add modifier 97 to the service or procedure code to indicate that the service or procedure provided was a rehabilitative service. Rehabilitative services help an individual keep, get back, or improve skills and functioning for daily living that have been lost or impaired because the individual was sick, hurt or disabled.”

The American Medical Association created these new modifiers through the CPT system, and they do not replace the –SZ modifier (habilitative services) developed by CMS and used by many non-Medicare payers. Clinicians should check with each ACA-compliant health insurance plan for specific details about using the new modifiers on the claim form.
Examples of habilitative and rehabilitative services provided by audiologists and SLPs are available.
ASHA will continue to provide updates regarding appropriate implementation and use of the new cognitive function intervention code and the habilitative and rehabilitative modifiers through ASHA’s website and future issues of The ASHA Leader. Sign up for ASHA Headlines and advocacy updates, and follow @ASHAAdvocacy on Facebook and Twitter.
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October 2017
Volume 22, Issue 10