Blue Cross proposes new policy for multiple therapy services

In 2022, Blue Cross Blue Shield of Michigan took the proposed payment reduction policy for physical, occupational and speech therapy through the Contract Administration Process. Based on the industry input that we received, the policy was put on hold.

Over the past couple of years, we’ve completed further analysis on the industry responses that lead to a policy modification. The proposed policy now excludes all therapy claims with a behavioral health diagnosis. With this change, Blue Cross is looking to implement this proposed policy in March 2025.

The proposed CMS multiple therapy policy will apply a reduction in reimbursement for the practice expense portions of therapy procedures when those services are the secondary or subsequent procedures provided on a single date of service by the same group physician and/or other qualified health care professional. This policy will not apply for therapy services rendered for behavioral health diagnoses.

• The rules align with CMS in determining which procedures are subject to the multiple therapy reduction and the primary or secondary ranking of these procedures based on practice expense relative value units, or RVU.
• The policy doesn’t interfere with benefit limits. Blue Cross allows 90 therapy visits per calendar year, and these rules won’t affect those limits.

What this means to facilities

When multiple therapy services are rendered on the same day, we’ll apply a “therapy pay percent edit.” The primary service will be reimbursed at 100% of the allowed amount, while secondary procedures performed on the same day will be reduced by 50% of the practice expense RVU.

The service with the highest RVU is considered the primary service. The practice expense RVU includes the nonphysician clinical and nonclinical labor of the practice, as well as expenses for building space, equipment and office supplies. Such expenses are considered duplicative for each subsequent therapy service and therefore will be reduced accordingly.

This practice expense reduction will result in an approximate average reimbursement of 83% of the allowed amount for all subsequent therapy services rendered on the same day.

The top five procedure codes that would receive the facility edit (reduced payment) include:

• *97140 – Manual therapy 1/> regions
• *97110 – Therapeutic exercises
• *97530 – Therapeutic activities
• *97112 – Neuromuscular reeducation
• *97116 – Gait training therapy

Input requested

According to the Contract Administration Process — part of the Participating Hospital Agreement that went into effect July 1, 2021 — we allow non-binding input from participating facilities about such proposals.

Input from facilities is requested by Oct. 31, 2024. Send any input you may have to Liz Bowman at ebowman@bcbsm.com.

After input is received, Blue Cross has 30 calendar days to respond.