• "It's an exciting time, to have this finally happening," Helene Fearon, PT, FAPTA, said at the conclusion June 6 of "Payment for Physical Therapy Care Is Changing." The session looked at the past, present, and future of efforts to shift payment for physical therapist services under Medicare from a fee-for-service model to what another speaker, APTA Senior Director of Payment and Practice Management Carmen Elliott, called a "value mindset."

    Elliott began with a historical view of the Department of Health and Human Services' mandate under the Affordable Act to meet the "triple aim" of payment reform—better quality of care, improved public health, and lower cost—and APTA's development of the Physical Therapy Classification and Payment System (PTCPS). The latter differentiates Current Procedural Terminology (CPT) evaluation codes by level of complexity for the physical therapist (PT), and differentiates intervention codes by severity of patient condition and intensity of PT services provided.

    Barbara Gage, PhD, a national expert on Medicare postacute care policy issues, then described pilot testing conducted last year of the reliability and validity of proposed new CPT codes in the 97000 series (physical medicine and rehabilitation). PTs in a variety of locations and practice settings were asked to apply the proposed codes to mock scenarios, and PTs at 2 locations—Intermountain Healthcare in Salt Lake City and the University of Pittsburgh—tested the validity and usability of the proposed codes by applying them to closed cases.

    While final results and recommendations are pending, sample comments suggested enthusiasm for the new evaluation codes but a need for additional clarity on what constitutes "moderate" complexity of clinical decision-making, Gage said.

    Fearon, considered one of the profession's preeminent experts on documentation, coding, billing, and payment-related policy issues, went into greater detail on the changes for which APTA has been working. The guiding principles (listed in full at www.apta.org/PTCPS/) can be summarized, she said, as changing the payment model from visit to episodic, fully using the clinical judgment of the PT, and taking into account the severity of the condition and the required intensity of PT involvement.

    APTA, Fearon said, defines low complexity of evaluation as involving, in part, a "focused" problem and stable patient presentation, moderate complexity as featuring an "evolving" presentation, and high complexity as involving an "unstable and unpredictable" presentation. Most evaluations conducted by PTs, Fearon noted, will fall into the moderate category.

    Fearon added that APTA is surveying a random sample of members to assess the "professional work value" of new CPT codes related to PT evaluations and reevaluations—part of the ongoing American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) process. (More information on the survey is available on the APTA website.)

    In addition to APTA's PTCPS page, Fearon cited 2 documents on alternative payment methodology as particularly relevant for PTs—the Medicare Benefit Policy Manual and the ICF (International Classification of Function, Disease, and Health) "beginners guide" (Toward a Common Language for Functioning, Disability, and Health).

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  • Last Updated: 6/8/2015
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