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  • APTA 'Deeply Disappointed' By CMS Decision on New Evaluation Codes in Proposed 2017 Fee Schedule

    Concerned for its members, the physical therapy profession, and the patients and clients served, APTA expressed "deep disappointment" this week that the Centers for Medicare and Medicaid Services (CMS) failed to adopt different payment values to correspond with 3 levels of physical therapy evaluation that the agency did adopt as new CPT codes in its proposed Medicare physician fee schedule for 2017. The association submitted formal comments to CMS on September 6, continuing its efforts on behalf of members toward the most meaningful and beneficial payment reforms.

    APTA strongly urged CMS to revert to the original recommendation from the American Medical Association Relative Update Committee (AMA RUC), which expanded the physical therapy evaluation and reevaluation codes from 1 each to 3 evaluation codes and 1 reevaluation code, including new values for each code. APTA reminded CMS that it conducted extensive analysis and research, and collaborated with many constituents over several years to develop the codes. The association maintains that the codes and the values assigned to them by the AMA RUC are "wholly appropriate to implement … as approved and vetted."

    Instead of adopting the entire recommendation, however, the proposed rule includes descriptors for 3 new evaluation codes and 1 new reevaluation code, but values all 3 evaluation codes the same—using the value of the existing single evaluation code. 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 (97164) also keeps the same value as its predecessor (97002).

    If CMS does not include the stratified payment values in the final rule, APTA strongly urged the agency to delay any future payment adjustments that would be based on analysis of claims filed in 2017 under the new codes. The association will work diligently with CMS to analyze billing patterns as providers are educated and become familiar with using the new codes, to prevent a negative impact on future payment. APTA also urged discussion of any viable options to delay implementation of the new codes if the tiered values are not applied to them. (After the release of the proposed rule in July, APTA had written to AMA asking that publication of the codes be delayed to allow additional time for member education. The request was denied.)

    As for the education effort, APTA outlined a major campaign to ensure that PTs and PTAs understand the new codes and learn to document appropriately for the 3 evaluation levels, even if there is no difference in their values for 2017. APTA will host a webinar (see below for more information), interactive self-paced learning module, website FAQs, and articles in its publications to support its members in the transition to the new codes. At the same time, APTA says it expects support and coordination from CMS, including getting APTA's input on the agency's own educational resources for physical therapy providers.

    APTA also responded to other provisions of the proposed rule, including the following.

    • In response to a request from CMS for input on 10 potentially misvalued physical therapy codes, the association confirmed its commitment to working through the process to ensure that the codes are assigned appropriate values. (As part of the process APTA members will be asked to participate in a survey this fall to provide input on how they are using these codes.) APTA requested the opportunity to discuss progress with CMS next year before release of the 2018 proposed fee schedule—to ensure that the voice of the profession is heard during the process and that the association's input is incorporated into the 2018 rule.
    • The association asked CMS to use its discretionary authority to permit PTs to perform telehealth services within alternative payment models such as accountable care organizations and the comprehensive care for joint replacement (CJR) bundled payment program, after the agency said it could not override federal law that as of now does not authorize PTs as telehealth practitioners.
    • APTA asked CMS to remove physical therapy from the in-office ancillary services exception to the physician self-referral, or Stark, laws. Given that in the proposed fee schedule CMS updates other aspects of the Stark law using broad authority it has to make modifications that "protect against program and patient abuse," APTA strongly recommended applying that same authority to remove physical therapy from the IOAS exception, arguing that this, too, would prevent abuse of the original purpose of the law.

    Members can read APTA's comments on the 2017 proposed Medicare physician fee schedule in their entirety on the Medicare Physician Fee Schedule page of the association's website. (Scroll to "APTA Comments.")

    Using your clinical judgment as a physical therapist to correctly classify patients' level of evaluation will be critical to collecting data as health care continues its move to value-based care, and to informing future payment for services. APTA's education efforts on the new evaluation codes include a webinar September 22, 2:00 pm–3:30 pm, free to APTA members. Register now at the APTA Learning Center.


    • The new evaluation codes are garbage in the first place. How does this have any impact on improving quality or demonstrating value? It's just another administrative headache. I hope CMS and the AMA scrap the whole thing. (I would also be interested in learning more about this "extensive analysis and research".) Over the last several years, we have seen increasingly burdensome regulations with no benefit to our patients or the advancement of the profession. Add this to the list. This does nothing to move us toward meaningful payment reform.

      Posted by Robert on 9/7/2016 6:03 PM

    • This seems like an unnecessary burden on the clinician, now without a financial incentive to do so correctly. More complexity in patient care is not the answer to improving quality of care. Seems like this info may only be useful for data analytics and not the clinician or patient.

      Posted by Craig on 9/7/2016 7:50 PM

    • The adoption of the codes should have been predicated on new payment. Instead we have more documentation with same pay which equals a net loss. I guess it's not an APS; it's an increased documentation system. Not so different than vision 2020 or even the DPT. Great ideas but poor execution has basically failed to move things forward. Seems like a huge oversight in planning and now back to the drawing board. Opportunity abounds but only if we can affect change.

      Posted by Chris on 9/7/2016 8:59 PM

    • After 42 years in practice and experiencing the continuous reduction in payment along with an expectation of increased documentation and expertise by PT, am not surprised at all by the latest CMS scheme to hurt us financially and require more intense evaluation decision making. Am concerned for the profession and the professional health of present and future PT staff under our current health system.

      Posted by Ray on 9/8/2016 3:51 PM

    • Our organization was one of the locations that was part of the "research" which was very cumbersome and poorly designed (in my eyes). It was very much like an outcome tool for both the patient and the clinician with missing items... Because of how cumbersome the process was many clinicians were exzcerbated by it as it took away from what needed to be done..not sure of the value of this study as I did not have a lot of "buy in" with the tool.

      Posted by Gerriann Samowski -> AJS]DG on 9/9/2016 12:26 PM

    • I see absolutely no value in creating different levels for our Evaluation codes. I have again, against my better judgement entered into the private practice realm knowing that healthcare and our profession are on a crash course of never ending administrative burdens and continuing ever shrinking reimbursement and declining job satisfaction. We as a profession have continuously, in the name of compassion, elected to give our services away. I've seen it for years where we don't consider documentation a billable component of our service yet we spend hours documenting the few moments we get in the hands on delivery of the clinical skill sets. We conrinuously imprison our profession by limiting our ability to actually use our professional judgement to delegate lower level treatment tasks such as ultrasound, estim, hot packs etched to trained technicians allowing us to actually practice the decision-making components of physical therapy. We utiize and even abuse every day unskilled levels of licensed PTAs being pushed into the delivery model though with the technical skills but without the assessment and judgement skills of daily evaluation and progression. We as a profession demand the tDPT as a profession standard and entry level for practice, when there is absolutely no valid data to support that this higher level degree brings me or anyone else a greater level of autonomy or reimbursement from the industry be it the third party payors or referring providers. Almost at the 2020 vision goal we have less reimbursement, more administrative overhead, higher educational debt load and greater attrition from our profession than ever before. Yet in spite of it all I still love the patients I servez. I will still foolishly meander my way toward a doctorate squandering thousands of dollars I'll never recover at the end of my professional years and accept the almighty invisibility of continued professional decline. Or maybe I'll just go fishing........

      Posted by Tina McLean on 9/10/2016 12:29 PM

    • Take a look at the world around us. The growth in concepts such as accountability and transparency have been eroding the relationships of caregivers and patients, teachers and students, government and citizens and countless others for years. These concepts seem reasonable but they assume a level of corruption in these relationships that put people in danger. And fear of danger has grown exponentially in our country. Just consider the restrictions placed on the free movement of children in there own communities compared to the past. There is no reason for optimism in the future either as these concepts now benefit third party businesses, lawyers and special interests who siphon off billions. I don't know how this will all end but it seems to me that it will become unsustainable at some point. Until then do what you can.

      Posted by Arthur Veilleux, PT on 9/11/2016 8:30 AM

    • For obvious reasons, the above feedback is consistent: More time spent documenting doesn't help the patient. We would be happy do demonstrate the solution. As we've done with G-codes and PQRS since 2013, we automate the 100 to 200 words required to defend the new eval code selection. Keep it simple; Your job is not to pick codes. Your job is not to write books defending codes. Your job is to restore the patient's functional deficits!

      Posted by Leon on 9/14/2016 11:15 AM

    • In reading previous comments on this, I think everyone sees this topic pretty clearly, more time spent documenting complexities, does NOTHING to resolve the patient’s complexities. In fact, it hurts the patient, as there is less time remaining for hands-on treatment. Since I started using my EMR in 2014, they have automated G-Codes and PQRS and they’ll do the same with eval codes and the necessary defensive documentation (100 to 200 additional words per eval!).I don't spend countless hours on verbose evaluations and I am complaint with all rules and regulations, I even get paid from Medicare for properly doing PQRS! My profits have gone up tremendously. I don't have to pay for continuing education on this topic. I can spend more time treating and gaining knowledge of how to heal my patient faster! Remember BOTTOM LINE: Our job is not to pick codes, or write books defending codes. Our job is to restore the patient’s functional deficits! I fully support The ATPA on this fight! WE as a profession have got to STOP "taking it" and start giving it! Join together for this fight!

      Posted by Jamie Rockwin -> =GQ[CL on 9/15/2016 10:02 AM

    • Who ever thought this up is a bureaucrat and not a practicing clinician! There are grave faults in the new criteria, most particularly in the clinical presentation criteria and how that relates to the other factors (history, exam and clinical decision making) that set the level of the eval code that should be used. I see many patients that are stable and yet are highly complicated, requiring a complex exam and higher level clinical decision making. Now the writing on the wall is that this scenario will be eventually paid the least! I get the concept, however the criteria do not support the concept.

      Posted by Elizabeth Henry, PT -> EGX on 12/17/2016 2:47 PM

    • What is interested is the details and complexity of the "long descriptors " for OT and short, poor description for PT. I looked at the descriptions and start to evaluate patients using this codes - majority of my patients falling in the category " low" however i wish CMS person will try to perform our eval in 20 min.

      Posted by robert on 1/2/2017 8:26 PM

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