Busting Medicare Part B Myths (and Regulating Your Expectations) Episode 1
PTA Differential, Estimated 8% Cut, ABNs, and More
By Kara Gainer, JD
The US Centers for Medicare and Medicaid Services (CMS) isn't known for easy-to-understand rules and regulations around Medicare. Unfortunately, that complexity can lead to misinformation, which can spread quickly.
In an effort to get everyone on the same page, I'm debunking some of the most prevalent Medicare myths I've been seeing lately on social media and in other venues. (Have a question that you would like addressed in a future installment? Send your ideas to firstname.lastname@example.org with "mythbusting" in the subject line.)
Myth: The PTA payment differential system is unprecedented, and CMS is solely responsible.
Although the planned payment differential system is problematic to say the least, it wasn't CMS' idea, and physical therapy isn't alone.
First, physical therapist assistants (PTAs) (and occupational therapy assistants, or OTAs) are by no means the first group to face a differential. In fact, throughout various incarnations of the Medicare physician fee schedule over the years, Congress has been coming up with differential reimbursement rates for a variety of professionals, including nurse practitioners, clinical nurse specialists, physician assistants, registered dietitians or nutrition professionals, and clinical social workers.
Second, federal law required CMS to establish a system by 2020 to denote when outpatient therapy services were furnished at least in part by a PTA or OTA, and beginning in 2022, to use that system to pay for services at 85% of the Medicare physician fee schedule. APTA, its members, and many other stakeholders had serious criticisms of and concerns for exactly how CMS interpreted the words "in whole or in part," and the system it would put in place for documentation. We've been able to get CMS to adopt several more reasonable provisions, but the fact is that the payment differential itself was dictated to CMS by Congress through law.
APTA Webpage: 2020 Medicare Physician Fee Schedule
APTA Quick Guide: Using the PTA Modifier
Myth: Physical therapy has been singled out for a possible 8% cut.
First, let's be clear: The estimated 8% cut CMS has proposed for codes related to physical therapy and occupational therapy beginning in 2021 is nonsensical, and will only reduce the ability of patients to get the care they need when they need it.
But the idea that PTs are the only profession taking the hit is mistaken. In attempting to raise reimbursement for codes related to evaluation and management (E/M) without increasing its overall budget, CMS decided to target multiple professions for cuts. In fact, 35 other professions are facing similar cuts, including a 7% decrease for emergency medicine, a 7% cut to anesthesiology, a 6% reduction for audiology, and 9% and 6% drops in payment for chiropractors and clinical social workers, respectively.
CMS was flooded with messages opposing the cuts, including a letter initiated by APTA that was signed by 55 members of Congress. In its final rule, CMS briefly acknowledged the opposition and said it will address the criticisms in future rulemaking. APTA is implementing a comprehensive, multipronged strategy for addressing the cut. We already know that any approach must involve working with other affected professions as well as mobilizing individual APTA members and nonmembers to add their voices to a grassroots campaign to let Congress and CMS know how the cuts could decimate care and put patients at risk.
APTA Webpage: 2020 Medicare Physician Fee Schedule
APTA Webpage: Medicare Fee Schedule Payment Reductions--Advocacy
Myth: CMS is the final word when it comes to supervision of PTAs in private practice versus institutional settings, always.
It's true that under Medicare, a PT must supervise PTAs. However, the level and frequency of supervision differs by setting—and by state or local law. PTs are licensed (and PTAs are either licensed or certified) in all states, the District of Columbia, and the US Virgin Islands.
Under Medicare, general supervision is required for PTAs in all settings except private practice, which requires direct supervision. But here's the thing: If state or local practice requirements are more stringent, the PT and PTA must comply with their state practice act. Example: Even though Medicare requires only general supervision in a skilled nursing facility when a PTA provides services, if a state practice act requires the PT to provide direct supervision then the state practice act must be followed. The reason for the different supervision requirements? Institutional settings must meet Conditions of Participation (health and safety standards established by CMS) and be surveyed by the state to ensure compliance with these standards, whereas private practices do not.
Medicare Benefit Policy Manual, Chapter 15: Covered Medical and Other Services (.pdf)
Myth: An advance beneficiary notice (ABN) can be furnished when the outpatient therapy threshold amount or targeted medical review threshold is reached.
Don't believe it. CMS is in fact very clear that payment liability cannot be transferred to a Medicare beneficiary when the thresholds related to use of the KX modifier or targeted medical review have been reached.
Let's break this down a little further. The KX modifier is required whenever the outpatient threshold ($2,080 of physical therapy and speech-language therapy services combined in 2020) has been met and additional therapy is medically reasonable and necessary. The therapist cannot avoid using the KX modifier by transferring liability of the amount above the threshold to the beneficiary by way of an ABN so long as the care is medically necessary. The therapist must apply the KX modifier to the claim to confirm that the services are medically reasonable and necessary as justified by appropriate documentation in the medical record. The beneficiary would be liable for the applicable copay for these covered therapy services.
The same applies for the $3,000 targeted medical review (MR) threshold: The therapist cannot transfer liability to a beneficiary for medically necessary services just because the incurred expenses for the calendar year have reached $3,000. Medicare covers therapy services at or above the $3,000 threshold that are medically reasonable and necessary; however, some claims exceeding this threshold may be subject to a targeted review to ensure their eligibility. In these cases, the therapist would continue to apply the KX modifier to the claim, and the beneficiary would be liable for applicable copay for covered therapy services.
What if the therapist furnishes services that are not medically reasonable and necessary and a valid ABN is issued? In those cases, the therapist adds the GA modifier to the line of service on the claim to indicate that an ABN has been issued and the services are not medically necessary.
CMS therapy services updates for 2019
Medicare Claims Processing Manual, Chapter 5 (.pdf)
CMS ABN Frequently Asked Questions (.pdf)
APTA webpage: Medicare Payment Thresholds for Outpatient Therapy Services
Myth: The direct care ("1:1") rule is a Medicare rule.
Actually, the language supporting the idea of "direct patient contact" appears in the American Medical Association's Current Procedural Terminology (CPT) book, in a section that accompanies the therapeutic procedure codes requiring that the "physician or qualified health care professional have direct (one-on-one) patient contact." The language is part of a resource aimed at providing a uniform language that will accurately describe medical, surgical, and diagnostic services—but it's not generated by CMS.
Medicare Claims Processing Manual, Chapter 5 Section 20.2 (B) (.pdf)
AMA Current Procedural Terminology Codes, 2020 edition (purchase required)
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Kara Gainer is APTA's director of regulatory affairs.
Read part 2 in this series.