Highmark's July 23 notice, August 31 policy roundup, and October 26 RP-051 preview
An approaching Highmark payment change gives occupational therapy practices a specific claim to check before October 26. The insurer will stop paying separately for massage therapy code 97124 when billed by providers designated in occupational therapy and several other specialties. Members cannot be billed for the resulting denial.
In brief
- The change takes effect October 26 for Commercial and Medicare Advantage products.
- The policy preview lists Pennsylvania, West Virginia, Delaware, and New York.
- Code 97140 requires the corresponding service and supporting documentation.
A July notice reaches its effective date
Highmark announced the change July 23 and repeated it in its August 31 reimbursement-policy roundup. The affected provider designations are occupational therapy, physical therapy, chiropractic, and physiatry. Its notice explicitly exempts massage therapists who bill as the rendering provider.
The upcoming version of Reimbursement Policy RP-051 lists Commercial and Medicare Advantage markets in Pennsylvania, West Virginia, Delaware, and New York, with CMS-1500 as the claim type. Practices should check their product and contracting arrangement against that scope. The preview explains that the member's benefit contract prevails if it conflicts with the reimbursement policy; a payment policy alone does not determine whether a service is a covered benefit.
New York needs a separate reading
RP-051 also addresses the multiple procedure payment reduction, or MPPR, for therapy. Its Medicare Advantage section says that MPPR reductions do not apply in the New York region. Immediately afterward, the massage provision expressly includes New York alongside Pennsylvania, West Virginia, and Delaware. The New York MPPR exception therefore leaves the new 97124 restriction in place.
For the affected specialties, Highmark says a billed 97124 service will receive a denial for separate payment and cannot be charged to the member. A practice preparing for October 26 could review its patient-statement rules so this denial does not automatically become a patient balance.
Review the service behind the code
Highmark's notice also addresses manual therapy code 97140. That code is appropriate only when the delivered service satisfies its CPT definition and the record supports it. Changing a charge entry simply to avoid the 97124 denial would leave that requirement unmet.
A useful preparation step is to identify which clinicians currently report 97124, review the services being documented, and discuss the change with the billing team before the effective date. These are suggested office checks. Questions about an individual contract or claim belong with Highmark, with the applicable product and provider designation in hand.