Policymakers are seeking ways to reform payment systems to achieve greater reporting accuracy, promote quality care, and reduce fraud and abuse. In the Balanced Budget Act of 1997, Congress charged the Centers for Medicare and Medicaid Services (CMS) to develop an alternative to the Medicare therapy cap-an arbitrary limit that restricts patient access to clinically appropriate services.
APTA's goal is to reform payment for outpatient physical therapy services to improve quality of care, recognize and promote the clinical judgment of the physical therapist, and provide policymakers and payers with an accurate payment system that ensures the integrity of medically necessary services.
APTA proposes to reform payment for outpatient physical therapy services by transitioning from the current fee-for-service, procedural-based payment system to a per session payment system. APTA believes that a system that categorizes patients based on the severity of their condition and intensity of the interventions required better reflects the professional clinical reasoning/judgment and decision making by the physical therapist, improves provider compliance, reduces administrative burdens surrounding current payment models, and is consistent with and enhances payer recognition of the value of physical therapist-directed care. To achieve this reformed payment system for outpatient physical therapist services, changes to the existing Current Procedural Terminology (CPT) coding system, which describes services based on 15-minute time-based units and direct one on one contact, would be necessary. Following these coding changes, the new codes will be valued through the AMA Relative Value Update (RUC) process and implemented in federal, commercial, and state-based payment systems.
Establishing new codes that physical therapists report for their services would be a significant change that would require therapists to learn the new codes and update billing systems. However, with elimination of many of the existing codes that therapists report and the many associated edits, administrative burden would be reduced. This bundled approach to the codes could result in more appropriate valuation of therapy services that better reflects the patient's condition and the clinical judgment of the therapist.
The alternative payment system (APS) would consist of 3 evaluation codes and 9 examination and intervention codes for a total of 12 codes. A physical therapist could conduct an evaluation and an examination and intervention service in the same day; otherwise a single examination and intervention code would be reported for the services that were delivered. Evaluation codes would be differentiated based on the level of complexity of the evaluation to the physical therapist-- limited complexity, moderate complexity, and significant complexity (refer to Table 1). Intervention codes would be differentiated into levels based on the severity of the patient's condition at the time of the visit and the intensity of services provided for the patient during that visit. The patient's severity would be determined to be either limited, moderate, or significant and the intensity of the therapy for that visit would be designated as limited, moderate and significant (refer to Table 2). Appendix A includes factors that could be used as a reference by the physical therapist to determine the patient's severity. The descriptors for each CPT code are included below. For each code, an illustration of a patient visit that would be reported using the code is included. These illustrations include a description of the patient's condition and characteristics and the intensity of the intervention provided by the physical therapist. The actual numbers in the boxes (1 through 12) are placeholders for possible future CPT codes.
Related APTA Policy
Reforming Payment for Outpatient Physical Therapy Services BOD P03-11-04-09
The APTA Board of Directors endorses the development of an alternative payment system for outpatient physical therapist services that transitions from a timed procedure-based system to one that recognizes the quality and value of physical therapist directed health care.