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  • 'Fundamentally Flawed': APTA's Comments on CMS' Plan Around PTAs, OTAs Target Potential Harms

    The big picture: a bad plan for determining when services are delivered by a PTA or OTA
    The US Centers for Medicare and Medicaid Services' (CMS) proposed physician fee schedule rule for 2020 includes provisions that would require providers to navigate a complex system intended to identify when outpatient therapy services are furnished by a physical therapist assistant (PTA) or occupational therapy assistant (OTA). If adopted, the plan would trigger a payment differential in 2022 based on how many minutes of services are provided by the PTA or OTA. (See this PT in Motion News story for a more detailed overview of the proposed rule.)

    CMS proposes to accomplish this by way of new PTA and OTA modifiers (CQ and CO, respectively) to be included on claims beginning January 1, 2020. The proposal also requires providers to add a statement in the treatment note that explains why the modifier was or wasn't used for each service furnished that day. In short, the system is rooted in total minutes of service, and would require the use of the applicable modifier that would indicate when a PTA or OTA provided outpatient therapy services for 10% or more of the total time spent furnishing the service.

    The proposal is more than just problematic—it's a threat to patient access to care, a vast overreach of CMS authority, and a documentation nightmare that flies in the face of CMS' "patients over paperwork" initiative to ease administrative burdens on providers. We laid out our concerns in a comment letter to CMS that describes the plan as "fundamentally flawed."

    Some of what's being proposed, CMS reasoning behind it—and what we have to say

    CMS: When the PTA participates in the service concurrently with the PT for a portion of total time, the modifier should be used when the minutes furnished by the therapy assistant are greater than 10% of the total minutes spent by the therapist furnishing the service, which means that the entire service would be subject to the 15% payment adjustment in 2022. This is being done to comply with Section 1834(v) of the Social Security Act.
    APTA: The intent of the therapist assistant provisions in the Social Security Act was to better align payments with the cost of delivering therapy services given that therapist assistant wages are typically lower than therapist wages. It was not meant to apply an adjustment to a PT's services furnished when the therapist assistant provides a “second set of hands” to the therapist for safety or effectiveness.

    The proposal completely ignores the efficacy of team-based care (CMS uses the term “concurrent“) and runs counter to the evolution—ostensibly supported by CMS—toward value-based care. "It is nonsensical to diminish reimbursement for services when safety precautions are implemented, and the overall value of the care is increased," we say in our letter. Bottom line: only services furnished in whole or in part independently by the assistant should count toward the 10% standard.

    CMS: If the PTA and the PT each separately furnish portions of the same service, the modifier would apply when the minutes furnished by the PTA are greater than 10% of the total minutes—the sum of the minutes spent by the therapist and therapy assistant—for that service.
    APTA: This proposal directly contradicts CMS' response to comments in the 2019 fee schedule final rule. In the rule, CMS explained how its claims processing system allows for the differentiation of the same procedure code when the same service or procedure is furnished separately by the therapist and assistant.

    In our letter, we write that “the agency clearly is contradicting itself now, several months later, in proposing to require that the CQ/CO modifier apply when the minutes furnished by the assistant are greater than 10% of the total minutes—the sum of the minutes spent by the therapist and therapist assistant for that service, thereby not allowing for the same procedure code to be reported on 2 different claim lines.”

    But that's just part of the problem. The system CMS is proposing for how providers arrive at this is anything but simple—in fact, we say that it's "outrageous that CMS expects therapy providers—particularly those who do not employ administrative staff and must perform all the coding and billing themselves in addition to delivering treatment to patients—to engage in division, addition, multiplication, and rounding merely to determine whether to affix a modifier to the claim."

    CMS: Beginning in 2022, if the PTA services exceed the 10% limit, reimbursements will be cut by 15%.
    APTA: The cuts pose a grave threat to the delivery of services, particularly in rural and underserved areas, especially when it's combined with the geographic indices that affect payment in these areas—on top of other potential reimbursement reductions in future years. We recommend that if CMS moves ahead with this proposal, it should exempt providers in rural and underserved areas from the requirements.

    CMS: In addition to the use of new modifiers, providers will need to provide a written statement explaining why the modifier was or wasn't used—and it has to be done for each service furnished that day.
    APTA: In our letter we call this plan "wholly unbelievable." Aside from the facts that the modifier proposal itself is extremely complicated and the extra documentation is not required by law, the addition of a statement requirement is clearly an undue administrative burden and a direct contradiction of the CMS "Patients Over Paperwork" initiative.

    We write that the plan "conveys a sense that CMS is being vindictive toward outpatient therapy providers, creating a divisive environment for therapy providers enrolled in the Medicare program." Our comment letter goes on to provide 6 additional reasons why the documentation requirement is a bad idea, including the ways in which it complicates 15-minute timed billing, exceeds requirements of Medicare administrative contractors, and applies a standard to PTs, OTs, PTAs, and OTAs that isn't applied to physicians, physician assistants, and nurse practitioners.

    What's next?
    This letter is the first of 2 comment letters on the fee schedule that APTA will be providing to CMS in the coming weeks. Deadline for comments is September 27, and the final rule will likely be issued by November 1. APTA and several other providers associations will be meeting with CMS officials in mid-September to share concerns and provide recommendations.

    You have an important role to play. Visit APTA's "Regulatory Take Action" webpage to access a customizable template letter on the PTA/OTA modifier, fill it in, and make your voice heard. It's easy—and crucial.

    Stay tuned for additional opportunities for comment on other elements of the proposed rule.


    • Does CMS cut reimbursement rates when a PA or NP delivers service ? Or require a modifier ?

      Posted by Lori Garone on 8/30/2019 5:06 PM

    • This is a detrimental to Assistants, noone will want to hire us because they will not get paid at the same rate, not only that it’s detrimental to patient care! It will be more work for the PT if they have to see a patient for a portion of each treatment and will just lead to Further career burnout for PTs! I feel as though they are trying to relegate assistants to the level of a tech, I didnt go to school and spend all that money to be considered a tech! Companies are already cutting PTA jobs with the expected upcoming changes in October! It’s only going to get worse. If they aren’t trying to treat PatAs as techs it sure feels like they are trying to push us out of the profession one wY or another. The service we provide are valuable and skilled regardless of it we have an associates degree or doctorate degree.

      Posted by Melissa Konechne on 8/30/2019 9:35 PM

    • Yes. Medicare reimburse PA and CNP at 85% of the physician fee schedule.

      Posted by Anonymous on 9/1/2019 6:31 AM

    • APTA, please create a social media profile picture badge and/or a simple infographic about this to create more buzz about this issue. This fleshed-out list is good, as well as on the APTA Take Action page, but we need something easy to share, with a quick link for more people to take action!

      Posted by Lisa Henderson on 9/2/2019 11:51 AM

    • You do realize that according to Medicare rules the PT must be present in the same office suite for a PTA to see the patient for Part B that means that a PTA can not stand alone you must have a PT. This is different from a PA or NP which is why they want to do this. In rural settings this is already difficult and costly now you have reduced reimbursement by 15 %. Most profit margins are less than 15 %. Also it is not fair that a PTA can work alone in all other settings for a portion of the time. PTA's are valuable to our profession. We have PTA's in our clinic that have incredible manual therapy skills and deep compassion for what we do.

      Posted by Katy Baker on 9/4/2019 12:57 PM

    • The clinical skills offered by CPTAs quickly exceed today’s DPTs.Time matters. Sadly, an eval post procedure is, in reality, an educated guess. success depends on communication. Build our DPTs up, but know a PTA/OTA spent 90%more time with the customer. Quality care post eval is what matters. A good worker should be paid for the quality of care provided, not by the minute. Ask the patient, or family. Especially the most prolonged stays or challenging circumstances. TEAM work matters. Sometimes it’s the CNA. I could go on and on. Be the best and try to stay humbled by the greatness keenly eyeing everything you accomplish.

      Posted by Andrew Robertson on 9/4/2019 7:01 PM

    • well since it's obvious that PTAs are being phased out, can we at least get more programs to allow for a transition from PTA to DPT. (more than just two in the whole US) I payed waaay to much money and learned way to much just be made obsolete due to insurance. PTAs should be allowed to challenge the DPT licensure.

      Posted by Joshua Klas -> CIWaCN on 9/5/2019 12:32 AM

    • This proposed flaw is that you, as the apta, are supporting the idea of screwing over the PTA as Melissa Konechne so clearly put it. You guys are wondering why the PTA membership is so low and are trying to find ways to up their numbers in the APTA, but you continue to only support ideas that support the PT only and screw over the profession of the pta. Your mission Statement is to support both the PTA and pt as equal yet your actions say otherwise. There is no reason why I, as a PTA should get paid 85% while you, supporting the PT only, should make 100% for the same sit to stand exercises, the same SLR, etc....APTA working for you....that is a joke...sure isn't working for me

      Posted by Kyle Suarez PTA on 9/5/2019 5:29 AM

    • I agree that this would compromise patient care further. It would most definitely be a documentation nightmare and lead to a decreased use of the PTA. The current system already accommodates for treatment provided by a PTA with delineation of the eval, re eval and joint mobilization/other interventions exclusive to the PT. This would threaten the PTA degree and further threaten and/or weaken the PT profession.

      Posted by Dr Mary Stout on 9/5/2019 6:48 AM

    • Any argument to thwart this proposal will have to be strong enough to illustrate differences between services provided by therapists/therapist assistants vs. physicians/physician assistants or any physician extender. What we should be focusing on is the commercial payers. Especially, those commercial insurance networks that manage State Medical Assistant plans via offspring LLC's these same networks own and 'cherry-pick' Medicare policy to their extreme benefit.

      Posted by David Bullock on 9/5/2019 9:12 AM

    • If this is CMS's approach to cutting costs, they are barking up the wrong tree. I have been a PTA for 37 years and have provided skilled PT treatments as efficiently and effectively as possible. There are evaluations and specialty areas that only the PT can be billed for but most other PT treatments are and should be billed the same. This proposal is not fair or sensible to the PTA or the PT/OT profession.

      Posted by Anne Reilly on 9/5/2019 10:10 AM

    • I agree with Lisa, "APTA, please create a social media profile picture badge and/or a simple infographic about this to create more buzz about this issue.” This response to CMS is a good first step by the APTA (I’ve been critical in the past but I can give just deserts when appropriate) and I'm thankful to see some action on this front. I feel the APTA should reach out to ALL licensed PT/PTAs, not just members for advocacy efforts. As a member, I and my fellow private practice owners have felt the APTA has been overly tame and ineffective with its support of our profession. This language in this prepared response to CMS is very welcome. Ramp it up, Keep it up and expand this topic into the social media and target all stakeholders, clinicians and general population alike. Really draw the contrast between what we do in the outpatient setting, when it’s done right, to manage pain and dysfunction without narcotics. I feel this is a great opportunity to reposition our profession as a first choice for many musculoskeletal and neuromuscular derangements during this time of changing the healthcare paradigm. This might end up being the catalyst that can help with the current gap in reimbursement and salary requirements for DPTs and PTA's alike, or it could just be another slam to our profession. Step it up APTA.

      Posted by Joe on 9/5/2019 11:30 AM

    • As I look to replace a departing PTA in 2 months, I have the opportunity to hire another very solid PTA, but wonder if this will be problematic in the near future. Its very difficult to find PT's/PTA's... and nurses, doctors, etc in the rural area where I live. But I wonder how much of an admin and budgetary nightmare this will be. If I don't hire this PTA, I may go 2 years without finding another provider. I may have to lay off support staff. And people with, say, an ankle sprain that could be better in 4-5 weeks, then get back to their life, may now have a life issue with this tricky ankle for the rest of their life, if they can't get in to be seen. What is the reasoning behind the 85% cut anyway? If they are saying services provided by PTA's aren't as valuable, why are they paying for them at all? In the evidence based era, is there evidence that services supplied by PTA's are less effective? Or is it just saving money? This is like having a 4 wheel car and saying tires are too expensive, so I'm going to cut off one wheel to save money on tires. You just ruined your car.

      Posted by James on 9/5/2019 12:15 PM

    • This true APTA should work for both PT and PTA AS A TEAM not with degrading the Profession. How many times APTA changed their VISION 2020?.

      Posted by Seihu on 9/5/2019 11:37 PM

    • From the comments so far, it should be obvious that the APTA needs to continue not only avoiding this infringement to therapy, but also to fight the change in pay being implemented in October.

      Posted by Jonathan Lee on 9/7/2019 12:01 AM

    • A line item modifier should be based on the PTA doing a percentage of the procedure, not total treatment time.

      Posted by Rick Wickstrom on 9/7/2019 6:52 AM

    • Let's get real here. This has been coming on for a very long time. Clinics and facilities have long been squeezing every drop of Medicare money that they can get out of every treatment, AND every patient. PTs, and especially PTAs, have been used as money making tools. Medicare is going broke and yes, our services are now rightfully being scrutinized under a microscope. I am sad for those of us who went into this profession thinking it was more than about money. We have been ruined by greed - NOT Medicare.

      Posted by Marie on 9/8/2019 7:31 AM

    • The APTA does it again. In their comments to CMS they basically say, "it's okay to cut reimbursement when a PTA does a treatment" I suggest to the APTA they study negotiating tactics. It is NOT okay to cut reimbursement at all, under any circumstances when a PTA does the treatment. There is a reason they are licensed! That license should allow us to get fully reimbursed when we utilize a PTA. And how dare the APTA to suggest otherwise. The APTA goes "belly up" too often!

      Posted by James F. Resing, PT, DPT on 9/8/2019 11:26 AM

    • One of my biggest concerns with this proposal is that companies will just use aides as PTAs instead of hiring PTAs. A well trained aide will be looked upon as someone who can do all the work as a PTA (aside from manual treatments) and then the company can still bill as a PT only saw them because aides aren't legally allowed to do that type of work. Cutting corners doesn't help anyone and the only people that are going to be hurt by this new rule are patients.

      Posted by Jennifer Arpin -> @KR`BJ on 9/8/2019 4:07 PM

    • Hi Marie. Your comment: "Clinics and facilities have long been squeezing every drop of Medicare money that they can get out of every treatment, AND every patient. PTs, and especially PTAs, have been used as money making tools." reminds me of when I worked for some larger corporations who were motivated by ROI, not patient outcomes. However, please consider the cost to CMS for a RTC or meniscectomy. We can agree these procedures cost CMS upwards of $10k, not to mention pain, suffering and in the case of the knee, eventually a really expensive TKA in terms of $ and painful recovery. Now, let’s contrast this with what we now know through evidence-based research, of which the APTA has made noteworthy progress in aligning our profession to more consistent treatment parameters, and the non-surgical recovery with just good old physical therapy. We now understand that these procedures are contraindicated until a competent physical therapist, physical therapy assistant team have seen the patient prior to surgery. In terms of the financial costs, the current cap for Medicare is $3,000 per patient per year. I believe most therapists observe this cap with regards to medical necessity, just because the audits over this amount have been made really cumbersome for the back of the house. We can agree this is a lot less expensive than the surgical choices, plus the added benefit of the rising tide of improved health and well-being is a valuable secondary benefit. Additionally, our clinic routinely addresses comorbidities and add additional treatment diagnosis because we believe treating the whole patient is our mandate, not just the knee or ankle. I don’t think this is “squeezing” CMS, I think this is being a responsible provider who is doing the patient and CMS a great service especially if we can avoid future falls and injuries leading to more costs. I think it's a good idea to step back sometimes and consider the entire healthcare landscape, evaluate where our profession currently is and where we should be in order to assess the cost to benefit analysis of our services. I would argue that PT is still the BEST value and still the most underutilized services in healthcare. Just my perception though.

      Posted by Joe on 9/11/2019 11:41 AM

    • If attempting to align with the APC to physician model then PTA's should be reimbursed at 100% if care completed incident to the PT and 85% if PTA is treating without in-suite supervision. This is not to align, this is to cut cost to CMS. If we areoving toward a value-based payment model then we should be reimbursed on outces regardless of the degree.

      Posted by Cynthia Long on 9/11/2019 4:55 PM

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