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  • Proposed 2019 Fee Schedule: Goodbye Functional Limitation Reporting, Hello MIPS?

    It's official: the US Centers for Medicare and Medicaid Services (CMS) is proposing that physical therapist (PTs) join the list of providers who must participate in the CMS Quality Payment Program (QPP), which would mean that beginning in 2019 PTs providing services under Medicare Part B must participate in either the Merit-based Incentive Payment Program (MIPS) or an Advance Alternative Payment Model (APM).

    But that's not the only significant change proposed by CMS. In a win for APTA and its members, the proposed rule would also eliminate functional limitation reporting (FLR), a requirement consistently opposed by the association.

    APTA regulatory affairs staff are reviewing the proposed rule and will provide more detail in the coming weeks. Here are the major takeaways so far:

    MIPS-eligible clinicians would include PTs
    PTs, occupational therapists, clinical social workers, and clinical psychologists who furnish services under Medicare Part B would be added to the list of providers required to participate in the MIPS program or, alternatively, an approved APM as part of the QPP. Currently, PTs may voluntarily participate in the QPP; if the proposed rule is adopted, the program would begin for PTs in 2019.

    MIPS requires reporting in 4 performance categories—quality, promoting interoperability, clinical improvement activities, and cost. Providers earn points in each category, producing a total annual MIPS score, which in turn determines whether the providers earn a payment incentive, remain neutral in payment, or be subject to a penalty. Several of the data points must be reported electronically through certified EHR vendors or registries such as APTA’s Physical Therapy Outcomes Registry. The inclusion of PTs comes as MIPS enters its third year of the program.

    (Editor's note: check out this article from PT in Motion magazine to get the basics on MIPS)

    Goodbye FLR?
    The FLR requirement, long-characterized by APTA as an unnecessary burden on PTs and other providers, would be eliminated under the proposed rule. Change or elimination of the FLR requirement was an ongoing target for the association, which provided data to CMS showing that the requirement didn't accomplish the value-based care goals that CMS envisioned.

    Physical therapist assistant (PTA) differential officially established
    Under the proposed rule, CMS would establish 2 new therapy modifiers to identify the services furnished in whole or in part by PTAs or occupational therapy assistants (OTAs) beginning. January 1, 2020. The change, mandated by the Bipartisan Budget Act of 2018, establishes modifiers to be used whenever a PTA or OTA furnishes all or part of any covered outpatient therapy service, and would set the stage for a planned payment differential that would reimburse services provided by PTAs and OTAs at 85% of the fee schedule beginning in 2022. CMS anticipates the creation of a voluntary reporting system for the new modifiers beginning in 2019.

    Payment would get a slight increase
    After applying adjustment factors mandated by the Bipartisan Budget Act of 2018, the proposed fee schedule conversion factor would be increased slightly, from $35.99 to $36.05.

    KX modifier requirements remain
    The permanent fix to the Medicare therapy cap enacted in 2018 included requirements to continue using the KX modifiers for claims that exceeded a threshold, which in 2018, is $2,010 for PT and speech-language pathology (SLP) services combined. CMS also references the targeted medical review process, noting the threshold amount of $3,000. That system would continue, but the proposed rule emphasizes that not all claims exceeding the threshold would be subject to review.

    More alternatives to MIPS
    Providers who elect to participate in the QPP through APMs would be allowed a bit more leeway in the new rule. For example, providers participating in the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration project would avoid MIPS reporting and payment adjustments if they participate in Medicare Advantage arrangements that are "substantially similar" to APMs.

    "The proposed rule contains provisions that, while not unexpected, have some far-reaching implications for physical therapists," said Kara Gainer, APTA director of regulatory affairs. "APTA will be analyzing the proposed rule in more detail and providing more information as it becomes available."

    The association will also be providing comments on the proposed rule by the September 10 deadline.


    • PTAs are done. No one will hire them now, much less at 85% reimbursement. And the MIPS vendor cost and time spent it won't be worth taking Medicare patients. Time to close shop and retire!

      Posted by Luke on 7/14/2018 11:39 AM

    • I read in a separate article that the MIPS reporting was for private practice only. Will MIPS be required for hospital based outpatient as well?

      Posted by Pete on 7/16/2018 9:10 AM

    • Guess we'll have to learn how to fabricate MIPS reporting, just like we faked it for the G-codes in order to get paid. If not, time to bail out like Luke suggested.

      Posted by Herb on 7/18/2018 4:15 PM

    • Blue Cross and Blue Shield started this lower reimbursement and it’s been proven that PTA’s are not wanted in the clinic because of lower reimbursement thanks to them. We have already seen the trend in outpatient settings. PT’s are already boasting that they don’t use PTA’s as a marketing ploy, now this finishes it for our careers. Bridge programs are few and far between and hard to access. Thanks CMS and BCBS! APTA, what are you going to do?

      Posted by Troy on 7/18/2018 4:36 PM

    • This specifically states for outpatient services: "The change, mandated by the Bipartisan Budget Act of 2018, establishes modifiers to be used whenever a PTA or OTA furnishes all or part of any covered outpatient therapy service, and would set the stage for a planned payment differential that would reimburse services provided by PTAs and OTAs at 85% of the fee schedule beginning in 2022." let's say for the sake of conversation that an LPTA generates $1000.00/per day in reimbursable rx's this would = $2,050,000 per yr, subtract the 15% PTA/OTA differential you get $1,742,500 per yr. Im not sure this spells disaster for PTA's? Maybe so if outpatient practices have low PTA numbers prior to the enforcement of the above proposed reductions. Continued discussion of any and all implications are warranted and welcomed.

      Posted by Jamie on 7/19/2018 10:35 AM

    • I have tolerated and adjusted to 40 years of regulation, restrictions, bundling, changed terminology, payment strategy reversals and falling reimbursement. In the meantime rent, salaries, billing and vendor/supply costs have gone up. No wonder it is hard to find therapists who want to be partners in private practice. Glad I just retired.

      Posted by John Romero on 7/19/2018 11:37 AM

    • If you take away 15%, in a small margin business like PT, you're just killing off a profession; one of the few well-paying professions which require only 2-3 years at an inexpensive community college. Contact your congressman. This goes against everything our country has become in the last 2 years.

      Posted by Sean Hayes -> =NX`?M on 7/19/2018 12:52 PM

    • I am not sure about PTA's not being hired due to lower reimbursement. I am a Physical therapist with Bachelor's in Physical therapy . All the Outpatient clinics in Plano Texas want to hire PTA's but not PT 's. They are willing to hire PT's with specialization or Doctorate only! Now I am working on getting Geriatric specialization through APTA and review of my application is itself is $525.00. I am debating if to pursue with doctorate or several specializations ? Any suggestions! Brindha Thirunavukkarasu.

      Posted by Brindha Thirunavukkarasu -> =OP_<K on 7/19/2018 1:41 PM

    • Has CMS and APTA worked on standardization of ALL data elements in the definitions of quality, cost, clinical improvement, and interoperability? When providers provide their own unique definitions and ratings, then once again we are in FLR mode with impossible analytics for interpretability. I would much rather have a reasonable DRG payment for OP patient categories that is risk-adjusted for patient severity. Then providers can manage their own metrics and cost to be competitive.Whether a PTA is utilized, or not would be immaterial (subject to state regulations of practice) Also- what about Part B payment in SNF and IP Acute services- are these going to be exempt or included in the new reporting?

      Posted by Ed Dobrzykowski, PT DPT ATC MHS on 7/19/2018 2:40 PM

    • @Pete: The proposed reporting requirements are for physical therapist private practices only at this point.

      Posted by APTA Staff on 7/20/2018 6:46 AM

    • Constant regulation changes and constant uncertainty in reimbursement and cuts that does not match the massive escalation in cost due to EMR and healthcare has forced me to close private practice after 19 years before its to late. We spend so much time with EMR to make sure visit is covered it takes away from patient care. The time it takes to document on all these EMR's are escalating cost of staffing. Reimbursement cuts are not keeping it into account. APTA y

      Posted by Annare Loubser on 7/21/2018 3:46 PM

    • Has anyone seen a notice that PTAs can now be reimbursed by the VA? Here in Oregon I worked hard with a great gal at Triwest and she finally got approval. I asked both VA and APTA to notify all of you but haven't seen anything. So spread the word! Part of the reason PTAs don't pay for themselves is because of all the things they can't do or can do but we don't get paid for. We just hired one and she's doing 6 patients to the PTs 12.

      Posted by Debbe on 7/21/2018 9:11 PM

    • In my practice, I co-treat with my PTA's. This ruling will mean a 15% reduction for all my medicare patients. At the same time the cost for a new EMR required by medicare is going to cripple me. STEP UP APTA. WHAT THE AM I PAYING MY DUES FOR. Do we all stop accepting medicare patients? With these rules I will lose money for treating them.

      Posted by Matthew Wensel on 7/22/2018 8:20 AM

    • We have a significant problem. We have an aging population, and a political institution that believes that having the uber 1% pay less in taxes is more important than health care for our fellow citizens. Medicare does not have enough money to do what it set out to do in '65 and what has been added to it through the decades. We PTs have benefited from that expansion. Hugely. I am in a small practice. 2 PTs and a PTA. Highest cost of living area in the USA. Yet paid by Medicare as if I am in a rural setting with a 30% reduction from my neighboring areas. If anyone can grip about the situation it should be me. I use an EMR. Yes it costs me about $350 a month and I spend more time on charting than ever. Dictation cost me about $600 and was blazing fast. I use FOTO on all clients and that costs me $115 a month. It shapes my educational efforts. It helps me market. It is a pain to track and I spend money on having an aide or reception help fold with it. These are what are required to be in practice. I got over it a long time ago. I think it would be helpful to get behind the spirit of MIPS and APM and see it as a way to increase quality over time and across the brand spectrum of health care. The APTA should not fight Medicare as much as the APTA should get involved with urging socially responsible policies that have a great bearing on our ability to fund and thus deliver health care. Sane tax policy, sane educational policy, sane foreign policy should be as much our goals as a sane regulatory environment for delivery of PT services.

      Posted by Jonathan Holtz on 7/23/2018 10:58 AM

    • This will drastically change the way PT's practice in smaller Rural towns. First there are not enough PT's to cover what is already an under-served area, without PTA's we will really struggle. I am the only PT in a 30 mile radius and have 3 PTA's that are amazing and help me with our small rural communities needs. We are a very busy clinic and without them, I would no longer be practicing , I'm sure because I couldn't keep up. I have been paying APTA dues for 30 years and expect that someone will acknowledge the struggles we already face, let alone this dramatic news. Please don't let this 15% cut to PTA services go through. Our livelihoods depend on it.

      Posted by Denise Ring -> @OP]? on 7/23/2018 2:47 PM

    • The great thing about physical therapy is we are so versatile, inventive and optomistic. Our profession has seen so many changes over the 15 years I have been in private practice and we still survive. The profession will continue to fight and we will survive this any anything else that is thrown at us.

      Posted by Kevin Lacey on 7/24/2018 1:39 PM

    • I’ve read several posts that say MIPS will apply to private practice clinics only. Why do hospitals which have much larger margins always get favorable treatment? Is it a simple matter of lobbyists? I would also argue that requiring direct supervision of PTAs should be eliminated if reimbursement is reduced. I don’t see how it is acceptable to require PT to be present, but not pay PT reimbursement rates.

      Posted by Bill on 7/27/2018 6:54 PM

    • I think Jamie's math is off. IF, and I mean IF, a PTA had a full list and made us $1000 a day, there are 52 weeks in the year times 5 days a week is 260 days times $1000 is $260,000. Minus 15% is $221,000. Subtract $60,000 salary, plus insurance and other benefits, their share of the salary of the billing person and receptionist, heat, lights, insurance, rent.....doesn't come out to $1.7 million in my experience! Then we lose money when the PT owner goes on vacation as the PTA can't treat Medicare and others without the PT present! So the PT owner doesn't even get paid vacation!

      Posted by Debbe on 7/30/2018 6:07 PM

    • Will CMS allow a PTA to see patients with indirect supervision in private practice? With PTA needing direct supervision I hire only PTs.

      Posted by James Adisano on 8/1/2018 5:18 PM

    • @James - Medicare requires direct supervision of PTAs in private practice.

      Posted by APTA Staff on 8/2/2018 7:59 AM

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