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  • Proposed Physician Fee Schedule: New Evaluation Codes, Same Payment

    With the release of the 2017 proposed physician fee schedule, the Centers for Medicare and Medicaid Services (CMS) is giving physical therapists (PTs) their first glimpse of a coding system that acknowledges varying levels of complexity in evaluations—though, for now, there is no difference in payment rates among those levels, and no changes from 2016 rates. Instead, CMS is calling for educational efforts to train PTs on how to appropriately use the new system. In addition, CMS continues its review of potentially misvalued codes, which includes 10 commonly used physical therapy codes.

    The proposed rule, which covers Medicare Part B services that apply to PTs, physicians, and other providers, incorporates work done by the American Medical Association (AMA) CPT Editorial Panel to retool current procedural terminology (CPT) codes for evaluation and reevaluation. PT in Motion News will publish more information on the rule in the coming days, based on an APTA staff analysis of the entire document. In the meantime, here are some features of the new rule that affect PTs.

    Evaluation codes will be tiered—pricing won't.
    CMS’ proposal adopts much of the system created by the CPT Code Editorial Review Panel. The new evaluation code descriptors stratify evaluations by complexity—low, moderate, and high—but in a departure from recommendations from the American Medical Association's Relative Value Scale Update Committee, they will be priced as a group rather than individually. That means CMS will keep the longstanding relative value unit (RVU) of 1.20 for all 3 levels of evaluation. The proposed rule also includes 1 reevaluation code with an RVU of .60.

    Education on the new codes will be key.
    The proposed rule calls for extensive PT education on how to appropriately code using the different evaluation levels—an effort that will be led by APTA. The association will provide detailed information on how to differentiate the number of personal factors that actually affect the plan of care and how to select the number of elements from any of the body structures and functions, activity limitations, and participation restrictions to make sure there is no duplication during the PT's examination of body systems.

    Work on potentially misvalued codes will continue, but look for changes in 2017.
    CMS has identified multiple potentially misvalued codes, including 10 commonly used in physical therapy, and has acknowledged that APTA and other specialty groups are working to develop proposed coding changes through the CPT process. In the meantime, CMS is looking for input on values. The potentially misvalued codes associated with physical therapy are: electrical stimulation, ultrasound therapy, therapeutic exercises, neuromuscular reeducation, aquatic therapy/exercises, gait training therapy, manual therapy (1/regions), therapeutic activities, self-care management training, and electrical stimulation (other than wound).

    The bottom line, however, is that Congress has set a .5% target for all misvalued codes in 2017 (not just the physical therapy-related ones). CMS believes that if the total misvalued code changes can account for a .51% reduction in net expenditures, it can avoid mandating a broad overall reduction in payment for services.

    At this point, payment rates for 2017 are unclear.
    Besides the fact that CMS doesn't publish conversion rates until it issues its final rule (usually late October/early November), the Medicare Access and CHIP Reauthorization Act (and elimination of the sustainable growth rate last year), coupled with the work on misvalued codes, make this year's situation somewhat different from previous years. MACRA is targeting a .5% update, but final payment rates will also be affected by the projected .51% reduction in the misvalued codes.

    CMS thinks allowing PTs to code for telehealth would take an act of Congress—literally.
    While CMS proposes to add several codes to the list of services eligible to be provided by way of telehealth, it's not going to add any physical therapy services to that list. Why? According to CMS, PTs are not listed in statute as authorized providers of telehealth services—and changing that would require congressional action.

    The rule also proposes tightening self-referral provisions, instituting new Medicare Advantage provider requirements, and introducing a new diabetes prevention program.
    With other notable provisions in the proposed rule, CMS hopes to smooth out a wrinkle that allowed a self-referral physician to levy per-unit rental charges to use space and equipment owned by the physician and leased to the referred facility, and aims to require all Medicare Advantage providers and suppliers to first be screened and enrolled in traditional Medicare. Also proposed for 2018: the Diabetes Prevention Program (DPP), a structured program that includes dietary coaching, lifestyle intervention, and moderate physical activity, all with the goal of preventing the onset of diabetes in individuals who are prediabetic. CMS is asking for comment on the program, including the enrollment of providers and suppliers as well as eligibility requirements for beneficiaries.

    APTA intends to comment on the proposed rule by the September 6 deadline.


    • Thank you for the summary looking forward to more education on this. One of the EMR companies, Clinician is already offering education on this.

      Posted by Christopher Dayger -> >LU\EF on 7/13/2016 3:51 PM

    • As I reviewed the Federal Register, I noticed that once again, OT is being valued higher than PT and PT evaluations are given shorter time than OT. Wondering why the discrepancy?

      Posted by Marsha Lawrence on 7/13/2016 4:20 PM

    • When will the MPPR go away?

      Posted by Melisa Crosby on 7/19/2016 11:58 AM

    • was so hoping that this would be the year that Speech and PT combined cap would be addressed.

      Posted by Denise Johnson -> ?NW`? on 7/28/2016 4:07 PM

    • Misvalued codes? MPPR has reduced all PT codes to extremely undervalued. Clinics with large M/C population are losing up to $600.00 per patient/per year. Does CMS really think further reductions for PT services can be considered? PT's still cannot opt out of M/C, regardless of how little CMS decides we are to be paid. Does anyone understand why PT is valued below OT or what the annual CAP of PT cost should have to do with the cost of Speech? These are obvious errors that needed to be fixed yesterday. Why were PT's not eligible for EMR incentives along with Mid-wives, Nurse Practitioners, etc? PT not being included in MACRA and continued PQRS for the next couple of years(good as that sounds) is not good for our profession. Now PT's not listed on statute as providers of telehealth services? "Meaningful Use" and technological advances are leaving PT behind. Athletic trainers, personal trainers and massage therapist have more freedom to treat and educate their clients than PT and trainers have been using telehealth for years. None of these professionals need to opt out of M/C to set prices and charge cash. Trainers and LMT do not have to stress over CPT, AMA, CAPS, PQRS, MACRA, RVU, EMR, MPPR, ICD-10, Functional limitation/severity modifiers, Outcome measurement tools, Electronic billing programs, Clearinghouses or LCD variations throughout the country. Best of all they will never have to worry about the next "extensive education" CMS decides PT and their billing staff must do that will never be reimbursed for. Just tired of trying to keep a private practice open with increasing overhead expenses and insurance companies slowly paying lesser amounts for service.

      Posted by Betty Fackler on 8/4/2016 12:53 AM

    • I fully agree with Ms. Fackler's comments. I feel the same frustrations along with my other private practice owners colleagues. I have also been a private practice PT owner since 1985 and now in 2016, we are still feeling similar negativity towards our profession. What is APTA doing or question is will APTA do anything to help private practice PTs. I have been paying my dues to my association since 1985!

      Posted by Hiten Dave on 9/19/2016 1:08 AM

    • I have also questioned many of the points made by Ms. Fackler. I don't see any marketing for the value of our profession. It is evidence based that PT for musculoskeletal conditions can decrease the need for opiates, diagnostic testing, and invasive procedures and surgery- a huge savings. At this time with pressure from healthcare changes for efficient, evidence based treatments why are we not in the forefront for triaging these conditions. Canada did a study using their advanced practice physiotherapists to triage orthopedic patients as the wait list was 2 years to see the specialist. They saved a ton of money and also weeded out many patients who then didn't need surgery. We spend over 4% of our GDP on musculoskeletal conditions and half of that has been deemed unnecessary- over $360 billion dollars per year! I can only talk to my referring MDs and educate them on sending patients the sooner the better for better outcomes, but where is the push from our profession to showcase these savings? Maybe the focus needs to shift or be more aggressive so PT isn't always scraping from the bottom of the barrel for every penny. Drives me nuts that OT gets paid more and ST and PT are combined let alone the ridiculousness about these new codes. Don't see how this is going to help us.

      Posted by Aimee Seiler on 9/21/2016 11:20 PM

    • What are the actual new codes? Have they been released yet?

      Posted by Brian on 10/6/2016 5:21 PM

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