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September 15, 2016
With the release in July of the proposed 2017 physician fee schedule from the Centers for Medicare and Medicaid Services (CMS) and APTA's comments in response in early September, we have a more defined outline of some key steps in the shift within health care toward value-based payment for services and away from the traditional fee-for-service model.
Two areas in particular call for our attention right now: the new evaluation and reevaluation CPT codes proposed under the 2017 fee schedule, and the review of potentially misvalued codes that CMS identified in the 2016 fee schedule. While these are different issues, they're united by several factors. Both provide an opportunity for APTA members to shape future value-based payment for physical therapy services; for example, in bundled payment arrangements such as the Comprehensive Care for Joint Replacement model and via quality reporting in the Merit-Based Incentive Payment System. Both empower us to elevate our practice for optimal patient care. Both signify the ongoing role physical therapists and physical therapist assistants can and should have within the changing health care environment.
And, for both, APTA is continuing its longstanding efforts on behalf of our members. The association and its collaborators have long been developing and implementing strategies to prepare for this evolution in payment, to ensure the best care for our patients and the best environment for fostering excellence in physical therapist practice. Most recently, I joined APTA CEO Justin Moore and other APTA staff in a meeting today with CMS officials, advocating for health care reform policies that benefit our members. But this is only 1 recent activity in a history of advocacy for meaningful health care reform since the Affordable Care Act in 2010—advocacy that continues as a priority of the association.
The CMS proposed physician fee schedule for 2017 introduced 3 new CPT codes for physical therapy evaluation and 1 new code for reevaluation. The new evaluation codes reflect 3 levels of patient presentation: low-complexity (97161), moderate-complexity (97162), and high-complexity (97163), and will replace the current 97001 code. The new reevaluation code replaces the current 97002. CMS failed to adopt tiered payment values for the 3 evaluation codes, as was recommended by the American Medical Association (AMA) Relative Update Committee. Our comments in response to the proposed rule reflect our disappointment and reiterate the recommendations we have made in strong support of stratified payment for different levels of complexity in evaluations. We will continue to voice these recommended changes to the proposal.
That being said, the tiered evaluation codes in themselves offer an opportunity for PTs to inform the eventual payment values that will be assigned to them in the future. By using the new codes appropriately and accurately, we can help shape future payment as we generate data that CMS can incorporate in its decisions on how these codes will be valued in the future. These new codes also empower us to use our clinical decision making skills in determining the complexity of our patients' and clients' conditions during an evaluation, so that we can better serve these health care consumers who come to us. This meaningful engagement up front with our patients is all the more relevant to our role in the current and emerging value-based payment systems that affect not just PTs but all health care professionals and are the goals of health care reform.
Related to this, while the evaluation codes are moving forward, corresponding proposed treatment or intervention codes did not progress through the AMA CPT process. The stakeholders in this phase of the coding reform effort determined that they aren't viable at this time, due to lack of consensus among members of the AMA work group assigned to review the codes, concerns by CMS that time was not a predominant factor in the codes, and concerns on the proposed codes' reliability and validity. The AMA work group has since been postponed indefinitely, and APTA does not plan to resume this initiative or to advance the body structure and function proposal that also was being considered by the AMA work group. Given the evolution of the coding reform initiative, APTA is not advancing its original proposal, the Physical Therapy Classification and Payment System, so that going forward our efforts reflect the progress of the association and other stakeholders.
The second issue at hand is the review of several CPT codes PTs use in daily practice. Outlined in the 2016 physical fee schedule, this "potentially misvalued" codes process brings specific CPT codes under review to determine if their assigned values are still appropriate or need to be adjusted. This will entail an AMA survey to APTA members, who will be asked to provide information on how they use each code in different patient scenarios. By responding to this survey completely and accurately we can help shape future payment—our responses are critical if we are to show how we use these codes in practice. Without our input, CMS and AMA will have little practical data "from the trenches" on which to base valuation decisions.
This survey is on a fast track—APTA members who are chosen to respond will receive the survey in late September or early October. The survey will be open for 2-3 weeks, to allow time before the end of the year to collect, compile, and analyze the data. The survey will be sent to a random selection of recipients, so if you're contacted, please take the time to respond to the survey in its entirety.
January 2017 is coming ever closer and, with it, certain changes to practice. As always, APTA will provide you with education and resources to meet the challenges of change and to empower you to provide the best possible care for patient and clients. I can't express enough my appreciation for your support—past, present, and future—in this huge endeavor.
Sharon L. Dunn, PT, PhD
President, American Physical Therapy Association