On the PTA Payment Battleground, We Are All APTA
By David Harris, PTA, MBA
I was working as a physical therapy technician when Congress instituted the Medicare cap on therapy services on January 1, 1999. I was to graduate as a physical therapist assistant (PTA) in May of that year, and, at that time, I had no idea or even much concern about what the cap would mean for our profession or my career.
I heard horror stories about layoffs of physical therapists (PTs) and PTAs due to the payment changes, but as a new graduate I was focused solely on finding a job in my chosen profession. It was not until years later, when I began working in outpatient care and seeing problems with payment, that I realized the importance of getting involved with advocacy.
Since that time, I have been as engaged as possible at the local, state, and national levels to be part of the solution to problems that arise for our profession, including payment for the services that we provide to our patients on a daily basis.
The therapy cap was part of the advocacy conversation for nearly 2 decades, but then, in 2018, there was a breakthrough: years of advocacy by APTA staff and members, as well as colleagues in other health professions, finally ended the permanent cap when the Bipartisan Budget Act of 2018 repealed it and replaced it with thresholds above which claims must include the KX modifier to indicate that services are medically necessary as justified by the documentation.
The repeal was a win, but it also created a challenge with regard to PTA services and payment: Beginning on January 1, 2020, outpatient therapy providers are required to use a CQ or CO modifier to denote when outpatient therapy services are furnished in whole or in part by a PTA or occupational therapy assistant. Starting in 2022, Medicare payment for these outpatient therapy services—as identified by the CQ or CO modifier—will be paid at 85% of the physician fee schedule (PFS) in effect for each year. The reduced payment rate applies to therapist services in private practice, outpatient hospitals, rehab agencies, skilled nursing facilities, home health agencies, and comprehensive outpatient rehab facilities.
These policy changes pose significant threats to patient access to quality care and to the overall viability of many practices throughout the country. Accordingly, APTA, along with several other stakeholders, began working with the Centers for Medicare and Medicaid Services (CMS) to ensure that the agency interpreted and implemented the policy in a manner that complies with the law's intent but imposes as little harm as possible to our patients and to clinicians.
During the remainder of 2018, APTA met with CMS in person and over the phone and submitted extensive comments in response to the 2019 PFS proposed rule that included CMS' definition of "in whole or in part." In all of the communications with CMS, including extensive comments in response to the 2019 PFS proposed rule, APTA put forward recommendations regarding how to define when services are furnished "in whole or in part."
In the 2019 PFS final rule, along with clarifying how CQ and CO modifiers would be used, CMS finalized a 10% "de minimis" standard under which a service is considered to be furnished in whole or in part by a PTA or OTA and thus require the modifier. APTA engaged in additional dialogue with the agency to help shape CMS’ implementation of the 10% de minimis standard in 2020 rulemaking.
When CMS published the 2020 Medicare PFS proposed rule this summer, the guidance on how it would apply the 10% de minimis standard immediately caused APTA and its members to have concerns. The proposed application was not only complex, it also was fundamentally flawed and would result in drastic underpayments for outpatient therapy services. One of our primary concerns was that, if the policy was finalized as proposed, CMS would be creating an access issue for Medicare beneficiaries.
Subsequently, APTA, along with several other associations, arranged an in-person meeting with CMS Administrator Seema Verma to discuss concerns with the proposed implementation. Representatives from APTA, the American Occupational Therapy Association, the American Speech-Language-Hearing Association, and the National Association for the Support of Long-Term Care attended the meeting and voiced our concerns. The meeting was the first time that APTA had been able to meet directly with Administrator Verma on this specific issue. Administrator Verma listened to our concerns and asked several questions on how this new rule would affect our patients and clinicians going forward. I felt like we were able to drive home the points of the increase in administrative burden with the new modifiers, as well as our significant concerns that the 15% reduction would limit patient access to care across the country, especially in rural and medically underserved areas of the country. This same sentiment was echoed in thousands of comments submitted by the physical therapy profession in response to the proposal.
Our collective efforts made a huge impact in the 2020 final rule: The CQ modifier will not be required when PTs and PTAs deliver services jointly (as when the PTA provides skilled services alongside the PT rather than separately from the PT), the de minimis standard will be applied to each unit of service, defined in a 15-minute increment, rather than to the total PT and PTA time spent furnishing the services, and the proposed documentation requirements were not adopted.
The take-away: We as clinicians have to get involved and stay involved. I have seen many comments about how the association has let us down on this issue. But, quite honestly, we—clinicians and students—are APTA, so we are ultimately responsible for being the "boots on the ground" for the association and the profession.
The battle for quality health care and appropriate payment for physical therapy services will probably never end, but it is vital that all of us in the profession understand that if we want to see positive change, we are the ones who can and must stand up and voice our concerns to our local, state, and federal legislators. I urge every clinician and student to reach out to their state and federal legislators regarding current and future proposed changes.
David Harris, PTA, MBA, is vice president of integrations at Upstream Rehabilitation and chief delegate of the PTA Caucus.