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  • Getting a Handle on the Fee Schedule: 6 Things to Know About the New PTA Modifier and Estimated 2021 Cut

    The physical therapy profession can breathe a little easier after convincing the US Centers for Medicare and Medicaid Services (CMS) to back off from some of its more troubling proposals around work done by physical therapist assistants (PTAs) in the final 2020 Medicare Physician Fee Schedule (PFS). But the rule still includes policies that are cause for concern for many in the physical therapy community: notably, a planned cut that's estimated to reduce payment to physical therapists (PTs) by 8% in 2021, as well as a system that will eventually pay less for services delivered "in whole or in part" by the physical therapist assistant (PTA) or occupational therapy assistant (OTA).

    In short, the 2020 PFS is a big deal. And at more than 2,400 pages, it's also just plain big, with several major components that affect PTs and PTAs in both good and bad ways, and plenty of context behind the details.

    You can read the entire rule to see for yourself, but before you do, here are 6 concepts that can help you understand what the profession is facing when it comes to the PTA modifier and estimated reimbursement cut in 2021.

    1. The application of the PTA and OTA modifiers were required by law—and will be broadly applied.
    The seeds that grew into the CMS rule requiring the use of modifiers were planted in 2018, when Congress passed (and the President signed) the Bipartisan Budget Act. The law required CMS to establish a system to denote when outpatient physical or occupational therapy services were furnished "in whole or in part" by a PTA or OTA, and beginning in 2022, to use that system to reimburse services at 85% when that "in whole or in part" line was crossed. The requirement applies to payments for physical therapy in private practice, outpatient hospitals, rehab agencies, skilled nursing facilities, home health agencies, and comprehensive outpatient rehab facilities.

    2. The modifier system could have been a lot worse than what's in the final rule. APTA members were a big reason for the improvement.
    When CMS proposed how the modifiers would be used—"CO" for OTAs and "CQ" for PTAs—it forwarded an needlessly complicated system that threatened patient care and ignored the realities of PT practice (this PT in Motion News story outlines the problems with the proposed rule from APTA's perspective).

    APTA members, association staff, and other organizations pushed back hard by way of thousands of responses to the agency. CMS took notice, and while it hung on to its "de minimis" standard that the codes must be used when 10% or more of the service is delivered by a PTA or OTA, it backed away from many of the more problematic elements of its proposed plan. This is how the modifier process will work:

    • The CQ or CO modifier is required to be affixed to the claim line of the service alongside the respective GP or GO therapy modifier. Claims that aren't paired appropriately will be rejected.
    • The CQ/CO modifier doesn't apply if all units of a procedure code were furnished entirely by the therapist. The modifier requirement does apply when all units of the procedures code were furnished entirely by the PTA or OTA.
    • Only the minutes that the PTA spends independent of the PT count toward the 10% standard.
    • The 10% standard is applied to each billed unit of a timed code (as opposed to all billed units of a timed code as CMS originally proposed), and the system allows for 2 separate claim lines to identify where the CQ/CO modifier does and does not apply.

    Need more information? Join APTA for a live Q and A session on the modifier system on December 3, and prep for the event by reviewing a pre-recorded presentation now available. And keep an eye out for a quick guide to the CQ modifier coming soon to apta.org.

    3. The 8% cut is an estimate based on an attempt to maintain "budget neutrality” and is proposed for January 1, 2021.
    There are 2 main concepts at the heart of the planned 8% cut: the complex nature of relative value units (RVU), and the idea that in order to provide additional money to 1 area in the fee schedule, CMS must pull money from other areas (budget neutrality).

    RVUs are the basic unit of payment in the feel schedule, and they're established by way of a formula that involves values for work, practice expense (PE), and malpractice (MP), adjusted for geographic costs variations and multiplied by a conversion factor (CF). In the final 2020 fee schedule, CMS sets out a plan to increase work values for office and outpatient evaluation and management (E/M) codes, mostly used by physicians. That adjustment would raise overall RVUs for E/M services.

    The problem is that as far as CMS is concerned, giving several codes more money means giving other codes less. CMS' approach—strongly opposed by APTA and organizations representing 35 other professions facing cuts—is to simply devalue elements that are used to calculate RVUs in other areas. The agency asserts that it can't say with certainty that the estimated cuts will be the reality of payment in 2021 because it's waiting to see how other budget adjustments might affect the fee schedule's overall bottom line in 2021.

    4. Opposition to the RVU plan was far-ranging, strong—and largely ignored by CMS.
    The physical therapy profession wasn't singled out for a cut to pay for increased E/M reimbursement. Among the 36 professions affected, estimated cuts include a 7% decrease for emergency medicine, a 7% cut to anesthesiology, a 6% reduction for audiology, and 9% and 6% drops in payment for chiropractors and clinical social workers, respectively. CMS was flooded with messages opposing the cuts, including a letter initiated by APTA that was signed by 55 members of Congress. In its final rule, CMS briefly acknowledged the opposition and said it will address the criticisms in future rulemaking.

    5. APTA is aggressively fighting the cut, and all options are on the table.
    APTA is evaluating its advocacy options and refining its strategy for addressing the cut. We already know that any approach must involve working with other affected professions as well as mobilizing individual APTA members to add their voices to a grassroots campaign to let CMS know how the cuts could decimate care and put patients at risk.

    In fact, the effort has already begun. Visit the APTA action center to send a message opposing the 8% cut to your representatives on Capitol Hill—it only takes 2 minutes.

    6. APTA wants you to be prepared for what's coming soon.
    While the 8% cut remains an unsettled issue, there are plenty of elements of the 2020 fee schedule that will begin in January. The association and its regulatory affairs staff have already created several resources, with more on the way. Available now:

    APTA Regulatory Review: Final Physician Fee Schedule for 2020. The big picture, more on the CQ modifier and estimated cut, plus an overview of other elements in the PFS, including the Merit-based Incentive Payment System (MIPS), KX modifiers, remote monitoring, dry needling, and more.

    Live Q and A on CQ modifier, December 3, 12 Noon (ET). Download a pre-recorded presentation and submit your questions in advance for a detailed discussion focused on the new PTA code modifier.

    Live Q and A: The Changing Landscape of Federal Payment, Coverage, and Coding Policies, December 10, 1:00 pm – 2:00 pm. Download a pre-recorded presentation and submit your questions in advance for a detailed discussion on a wide range of issues related to federal payment: the PFS, MIPS, TRICARE, and more.

    Insider Intel: PFS, MIPS, and more. A recording of a November 20 phone-in session with APTA regulatory affairs staff that touched on a wide range of payment topics, many related to the PFS.

    Information on the updated KX modifier thresholds and exceptions. The 2020 PFS includes a slight increase in the limits on therapy provided before the KX modifier is applied. Learn more here.

    Coming soon: a written guide on how to apply the CQ modifier, a webpage devoted to the 2020 Medicare changes, a 2020 multiple procedure payment reduction (MPPR) and sequestration fee schedule calculator, advocacy information on fighting the 8% cut, and more.

    US House Approves Bill to Help Fund Greater Diversity in PT, Other Health Care Education Programs

    APTA-supported legislation to encourage greater diversity in physical therapy programs has cleared an important hurdle: this week, the US House of Representatives passed a bill that would appropriate additional federal money for scholarships and stipends for students from underrepresented populations. Next stop—the US Senate.

    The bill that passed the House unanimously, called the "Educating Medical Professionals and Optimizing Workforce Efficiency and Readiness for Health Act" ( HR 2781) broadly focuses on educational issues in health care. Included in that bill was the Allied Health Workforce Diversity Act of 2019, a bill that specifically targets education programs in physical therapy, occupational therapy, audiology, and speech-language pathology. The diversity act was sponsored by Reps Bobby Rush (D-IL) and Cathy McMorris Rodgers (R-WA) and strongly supported by APTA.

    The diversity act would provide grants for use by accredited education programs in physical therapy, occupational, therapy, audiology, and speech-language pathology. The funds would allow programs to issue scholarships or stipends to students from racial and ethnic minorities, as well as to students from disadvantaged backgrounds including economic status and disability. That bill was included in its entirety as part of the broader health care education package.

    The provisions are consistent with APTA's strategic plan, which identifies greater provider diversity as necessary to ensure the long-term sustainability of the physical therapy profession. APTA, the American Occupational Therapy Association,the American Speech-Language-Hearing Association, and the American Academy of Audiology are working together to press for adoption.

    "The idea that health care professions should be as diverse as the populations they serve is an important one for APTA, and this legislation is a welcome step in the right direction," said APTA President Sharon Dunn, PT, PhD. "Diversity strengthens our profession, which in turn makes us better able to meet the needs of our patients and clients. That diversity must include the education programs that are creating the next generation of physical therapists and physical therapist assistants."

    “We are grateful to Representatives Bobby Rush and Cathy McMorris Rodgers for their leadership and support in getting this bipartisan bill through the House of Representatives,” said Justin Elliott, APTA vice president of governmental affairs. “We are also grateful to all of the APTA members who advocated in support of this important legislation.”

    A companion bill is expected to be introduced in the US Senate on Wednesday, October 30.

    The legislation is just one of several bills and issues APTA is advocating on during this session of the US Congress, which includes APTA-supported legislation aimed at addressing administrative burden and prior authorization (HR 3107), PT student loan debt (HR 2802/S. 970), home health payment issues (S 433 / HR 2573), Medicare fee schedule, self-referral, and more.

    APTA: New SNF Payment System Should Drive Quality Patient Care, Not Staff Layoffs

    Fewer than 48 hours after the launch of a new Medicare payment system for skilled nursing facilities (SNFs), APTA began receiving word from physical therapists (PTs) and physical therapist assistants (PTAs) that a number of providers were announcing layoffs or shifts to PRN roles with reduced hours and fewer or no benefits. Many were told by their employers that the new system, known as the Patient-Driven Payment Model, or PDPM, was the reason for reduced staffing levels and less therapy.

    There's one problem with that explanation: it isn't true.

    That's the message APTA is delivering to SNFs, association members, and the media as it works to debunk myths surrounding a system that was designed to support clinician decision-making and push SNFs toward a more patient-focused payment model.

    "Yes, this is a new payment system, but it doesn’t change the reality that staffing and service delivery must continue to be grounded in quality patient care," said Kara Gainer, APTA's director of regulatory affairs.

    What PDPM changes—and what it doesn't
    The US Center for Medicare and Medicaid Services (CMS) describes the PDPM as an attempt at "better aligning payment rates…with the costs of providing care and increasing transparency so that patients are able to make informed choices." In that sense, PDPM is another step in the overall evolution of health care toward a more outcome-based, patient-focused system. And it didn’t arrive out of nowhere: CMS has been floating proposals for revamping SNF payment since at least 2017.

    Still, the new system, with its basis on classifying SNF residents among 5 components (including physical therapy) that are case-mix adjusted and employing a per diem system that can be adjusted during a patient's stay, marks a big change for SNFs. For SNFs that embraced volume-based approaches to care, the shift is even more significant.

    That may be true, Gainer said, but some of the most important elements of PDPM are the things that haven't changed under the new system.

    "Absolutely nothing changed between September 30 and October 1 [the startup date of PDPM] about patient needs in SNFs, or the value of physical therapy in meeting those needs," Gainer said. "PDPM is predicated on the idea that rehabilitation professionals will exercise clinical judgment and furnish reasonable and necessary services to patients."

    APTA created a 1-page handout that summarizes what's different about the PDPM—more patient focus, reduced administrative burden, a new definition of group therapy and a 25% combined limit on group and concurrent therapy, and a new way to determine function scores—but the resource also points out what remains unchanged: medically necessary care as a baseline standard, the criteria for skilled therapy coverage, and the centrality of clinical judgment, among other elements. Additionally, the need for daily skilled nursing services or rehabilitation services has not changed.

    The bottom line, according to Gainer, is that decisions that override clinical judgment and reduce or compromise patient care shouldn't be attributed to any requirements contained in PDPM.

    "Assertions that the PDPM mandates cuts in care are untrue, as are claims that PDPM requires the maximum use of group or concurrent therapy, sets out productivity requirements, and dictates how many minutes of care therapists can provide based on payment categories," Gainer said. "Whether deliberate or simply a misinterpretation of the rule, these myths need to be put to rest."

    A big incentive for SNFs to get past the myths: CMS is paying attention
    As APTA members began sharing their stories of layoffs and status shifts attributed to PDPM, APTA President Sharon Dunn, PT, PhD, took to Twitter with a simple message:

    "PDPM changed Medicare payment methodology for SNFs on Oct 1. It did not change the value of physical therapy services or patient needs. Reducing PT and PTA staff 46 hours into this model reflects poorly on the commitment to patient access and quality of care. And CMS is watching."

    SNFs should pay particular attention to the last sentence of Dunn's tweet, Gainer said.

    "Anyone who's followed CMS rulemaking over the past few years knows that patient outcomes data and their link to plans of care are becoming extremely important in how CMS shapes payment and other rules—and rightly so," Gainer said. "CMS has already indicated to us that they are closely monitoring the actions of health care facilities post-PDPM to determine if patient needs are driving decision-making, and may propose changes to counter any trends that impede the overall goals of the system."

    In an interview for an article on PDPM published in Skilled Nursing News, Robert Lane, a consulting director for health care consulting firm BKD, called the SNF layoffs and adjustments "premature," and stated his surprise that the SNFs didn't "pump the brakes a little for 90 days to see where we're at after the first quarter, couple of billing cycles."

    And like Gainer, Lane told Skilled Nursing News that it's certain the sudden drastic changes will "draw attention from CMS."

    APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association have issued a joint statement noting that they have shared reports of layoffs directly with CMS and will continue to keep the agency abreast of reductions that put patients at risk.

    APTA's continued work
    The first versions of what evolved into PDPM emerged in spring of 2017, and APTA immediately began advocating to CMS on behalf of patients and the physical therapy profession. The association's efforts, fueled by member engagement, led to some significant changes to the final rule—including CMS' decision to implement a combined limit of 25% of group and concurrent therapy.

    But now, with PDPM in place, APTA's efforts need to shift to careful monitoring of how the rule is being interpreted and implemented, and its impacts on patient care and the PTs and PTAs providing that care. The reason is simple, according to Gainer: rules can be changed.

    "Another myth that's being circulated is that the PDPM is now written in stone and that no adjustments can be made," Gainer said. "That has never been the case with rules from CMS, and certainly isn't the case with this system—especially given the amount of attention CMS will be paying to how SNFs interpret and implement PDPM, and the degree to which those changes impact patient access to medically necessary care."

    Get the facts on PDPM and stay up-to-date on news about the new system: visit APTA's Skilled Nursing Facility and Home Health Payment Models webpage. Do you have your own story about how the PDPM has affected your work? Contact advocacy@apta.org.

    Where Things Stand, What APTA's Doing: Fee Schedule, SNF, and HH Rules From CMS

    The Centers for Medicare and Medicaid Services (CMS) spends much of its spring and summer churning out regulatory rules for the coming fiscal and calendar years. That means it's an equally busy time for APTA, its members, and other stakeholders to stay on top of the proposals, respond to whatever challenges emerge, and advocate for change when needed.

    This year's standout challenge: advocacy efforts around the CMS proposed physician fee schedule (PFS). The rule as proposed includes at least 2 troubling provisions that demanded a strong response—1 around how CMS would go about determining whether therapy services were delivered "in part" by a physical therapist assistant (PTA) or occupational therapy assistant (OTA), and another that proposes an estimated 8% cut to reimbursement for physical therapists (PTs) and several other professions.

    APTA has been aggressively fighting these changes through comments, creating a platform to facilitate a flood of individual member letters to CMS, multiprovider organization sign-on letters, meetings with CMS representatives, and the latest: a bipartisan letter signed by 55 members of Congress urging CMS to rethink the cuts.

    So where do things stand with CMS rulemaking, and what is APTA doing around the PFS and other developments? Here's a guide to 3 of the biggest rules issued to date in 2019, along with information on our advocacy efforts.

    Medicare Physician Fee Schedule
    Status: Proposed (comment period closed); final rule expected in early November

    Quick take
    A misguided attempt by CMS to define (and pay less) when services are delivered "in part" by a PTA or OTA, and an arbitrary 8% cut in 2021 to PT and OT services as well as similar cuts to services furnished by clinical social workers, clinical psychologists, audiologists, and other providers could have major impacts on patient access to care. The rule also includes changes to the Merit-based Incentive Payment System (MIPs) and other areas.

    Our advocacy

    Resources: CMS fact sheet; PT in Motion News stories on PTA modifier and proposed cut; recorded webinar (from August 15); upcoming "Insider Intel" phone-in session (November 20)

    Skilled Nursing Facilities (SNFs) Prospective Payment System
    Status: Final, effective October 1, 2019

    Quick take
    CMS followed through with plans to dramatically change the payment system for SNFs by adopting the Patient-Driven Payment Model (PDPM), a system based on a resident's classification among 5 components (including physical therapy) that are case-mix adjusted, and employing a per diem system that adjusts payment rates over the course of the stay. In a win for APTA and its members around group therapy, CMS moved away from a rigid 4-person definition and adopted the association's recommendation that the definition of group therapy as 2 to 6 patients doing the same or similar activities—the same definition used in inpatient rehabilitation settings.

    Our advocacy

    • APTA comment letter
    • In-person meeting with CMS representatives
    • Multiprofession coalition sign-on letter
    • Templated comment letters for individual clinicians

    Resources: CMS fact sheet; APTA fact sheet; PT in Motion News stories on proposed and final rule; APTA SNF PDPM webpage; recorded webinar series; recorded Insider Intel session (May 22)

    Home Health Prospective Payment System
    Status: Proposed for 2020 (comment period closed), final rule expected in early November

    Quick take
    Similar to its efforts around SNFs, CMS wants to transition to a new payment system for home health agencies (HHAs), known as the Patient Driven Groupings Model (PDGM). That system moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. The proposed rule would also allow PTAs and OTAs to perform maintenance therapy services under a maintenance program established by a qualified therapist and would end the HHA split payment approach in favor of a more efficient notice-of-admission approach.

    Our advocacy

    Resources: CMS fact sheet; PT in Motion News story on proposed rule; APTA webpage on PDGM; recorded webinar (August 5)

    Other advocacy efforts
    APTA has also provided comment letters on CMS rules on outpatient payment, Medicaid access, inpatient rehabilitation facilities, and hospital payment; and signed on to multiprofession coalition letters to CMS on outpatient payment and rules around durable medical equipment, prosthetics, orthotics, and supplies.

    Stay tuned
    As APTA continues to advocate for the profession, the association also provides its members with plenty of opportunities to get up-to-speed with both proposed and final rules. Keep the following upcoming events on your radar for more insight on payment and regulation:

    APTA to CMS: Proposed 8% Cut is 'Arbitrary' and Puts Patients at Risk

    The big picture: APTA is fighting a "nonsensical" and "arbitrary" plan to cut physical therapy reimbursement by 8% in 2021.
    The US Centers for Medicare and Medicaid Services' (CMS) proposed physician fee schedule (PFS) rule for 2020 is, as always, a wide-ranging plan that affects multiple types of providers. But this year, physical therapists (PTs), physical therapist assistants (PTAs), and the patients they serve are facing a particularly pointed threat: a cut to the reimbursement codes most often used in physical therapy. Combined, these reductions would reduce reimbursement by an estimated 8% in 2021. APTA's comment letter to CMS lays out how the cut could dramatically reduce patient access to effective care, forcing many PTs and other rehabilitation providers to leave Medicare or shutter their doors entirely.

    The comment letter also addressed numerous other provisions in the proposed rule, including changes to the Merit-based Incentive Payment System (MIPS), remote physiologic monitoring, digital evaluation, dry needling codes, and telehealth. Additionally, APTA reiterated many of its concerns regarding CMS’ proposal for determining when therapy services are delivered "in whole or in part" by a PTA or occupational therapy assistant. Those concerns were communicated to CMS in detail in August in a comment letter that described the plan as "fundamentally flawed." APTA and 2 of its members, along with 3 other associations, met in-person with the CMS Administrator earlier this month, echoing the same concerns.

    The proposed cut, and why it's a bad idea
    The cuts are associated with a CMS plan to adopt the American Medical Association-recommended increases in values for office/outpatient evaluation and management (E/M) codes, an increase that APTA sees as generally positive. The problem is in CMS' approach to paying for the increase.

    In order to adopt those increases and maintain budget neutrality, CMS proposes cuts to other codes to make up the difference. We believe there are other, more valid ways to respond: seeking additional funding for the increase; applying negative adjustments uniformly across all services; not excluding any specialties, procedures, or service codes; increasing the conversion factor; and phasing in any proposed reductions would be "appropriate and necessary" actions to take, as stated in our letter. Instead, CMS attempts to keep the E/M increase budget neutral through a seemingly haphazard approach that lowers reimbursement for non-E/M codes, resulting in the most drastic cuts to reimbursement for providers who don't bill E/M. That list of providers isn't limited to PTs and occupational therapists—it also includes audiologists, clinical social workers, clinical psychologists, ophthalmologists, optometrists, chiropractors, and more.

    In our comment letter to CMS, we point to 5 major areas of concern:

    1. The plan is an arbitrary, across-the-board cut that doesn't account for reimbursement decreases in other areas.
    We argue that PTs have been the target for cuts through other policies such as the multiple procedure payment reduction (MPPR), sequestration, Correct Coding Initiative edits, and by way of a 2018 revaluation of current procedural terminology (CPT) codes, particularly to the practice expense (PE) of certain codes. When those reductions are combined with the proposed 8% cut, on top of the pending 15% reduction in payment for services furnished by PTAs and OTAs in 2022, the reductions for many PTs could be closer to 23% in 2022. We call that an "unrealistic" plan that will lead to a "significant decline in beneficiary access" to physical therapy.

    2. The cut runs counter to CMS' efforts to provide patient access to better care.
    Both the US Congress and the Department of Health and Human Services emphasize the importance of a Medicare system that supports integrated team-based care, chronic disease management, and reducing hospital admission and readmission rates—concepts that are central to PT practice. Given this emphasis, we write, it's "nonsensical" to cut reimbursement to the very professionals who play key roles in achieving these aims by decreasing functional limitations and increasing strength and flexibility deficits.

    3. In the midst of an opioid crisis and a national conversation on pain management, CMS should be promoting physical therapy, not decreasing patient access to it.
    Research makes the case over and over again: physical therapy lowers overall costs of care, and is an effective pathway for management of many types of chronic pain. We ask CMS to explain how the proposed 8% cut supports those ideas, and argue that if Medicare beneficiaries are in need of access to effective nonpharmacological pain management treatments, "there must be adequate payment and coverage."

    4. There was little transparency and a seeming lack of responsible analysis in the development of this proposal.
    The Regulatory Flexibility Act requires CMS to conduct a regulatory analysis of changes, such as the 8% cut, including the ways it would affect small businesses and possible options for achieving its goals that reduce economic impact. If such an analysis was conducted, it doesn't seem to be reflected in the plan, which clearly puts PTs and many other providers at risk. We write that CMS' nontransparent approach and lack of dialogue with providers may have led to "many flawed assumptions regarding practice."

    5. The cut includes unfair reductions to practice expense (PE).
    PTs have seen reimbursement for PE—costs incurred in renting office space, purchasing supplies and equipment, hiring nonphysician and administrative staff, and more—decreasing since 2011, when CMS started introducing cuts through MPPR. APTA has always held that applying MPPR to PTs was inappropriate in the first place, and often results in underpayments. The proposed cut includes a PE reimbursement decrease of at least 3%. We write that it's a plan that puts "expediency ahead of quality." Instead, we argue for the removal of the proposed cuts to the PE values of codes used by physical therapists and that CMS recoup that money by looking to those codes used by providers "who do not have as demonstrable costs for equipment and supplies as physical therapy providers."

    What's next?
    The comments are one part of a multifaceted approach to advocacy against the proposed cuts. APTA members, patients, and other stakeholders have joined a grassroots effort opposing the plan, and the association has joined with the American Chiropractic Association, the American Psychological Association, the American Occupational Therapy Association, the American Speech-Language-Hearing Association, and 5 other professional associations in a letter opposing the cuts and requesting additional dialogue. APTA will continue to work with CMS to educate them on the negative consequences on patient health if this reduction is implemented. APTA and our members will also have a second formal opportunity to fight any proposed cut in the 2021 proposed fee schedule rule that will be released in July 2020.

    After the deadline for comments closes at 11:59 pm on September 27, CMS will begin its review process. The final rule is expected to be released in early November.

    Reading this before 11:59 pm on September 27? There's still time to add your voice to the effort. Visit APTA's "Regulatory Take Action" webpage to access a customizable template letters on both the proposed 8% cut and the PTA/OTA modifier proposal. It's easy—and crucial.

    APTA Student-Led 'Flash Action' on Federal Loan Repayment Program Sets Record

    Capitol Hill now has 14,000 additional reasons to increase access to physical therapists (PTs) in rural and underserved areas—and to provide student debt relief to some PTs along the way—as the result of one of the most successful APTA "flash action" events to date. And the profession's students can claim much of the credit.

    This year's Flash Action Strategy (FAS) event, held September 18 and 19, focused on advocacy around the Physical Therapist Workforce and Patient Access Act (HR 2802/S 970), a proposal that would include PTs in the National Health Services Corps (NHSC) and its loan repayment program. Participants in NHSC can receive repayment for up to $50,000 in outstanding student loans when they agree to work for at least 2 years in a designated Health Professional Shortage Area. This increased access to physical therapy instead of opioids for pain management could help reduce consumption of the drugs in some areas of the country hardest-hit by the opioid crisis.

    In the midst of already-packed semesters, students from multiple PT and physical therapist assistant (PTA) programs took time to participate in the nationwide effort, primarily using social media to concentrate their efforts during a 48-hour window of intense messaging. The students were joined by PTs, PTAs, and other stakeholders to generate a total of 14,148 communications advocating for passage of the legislation—the most ever delivered during an APTA FAS since its beginnings in 2013.

    "FAS is an opportunity for our voices to be amplified because of our unity, but it's also a reminder that each voice matters," said Kate Zenkder, SPT, member of APTA Student Assembly Board of Directors. "We hope the FAS is really just the beginning of a conversation with our representatives that should take place all year round about how we can all work to transform society. We can be a part of real change and transformation, but we need to join that conversation."

    PT and PTA students will bring their energy and excitement to the upcoming APTA National Student Conclave, set for October 31 to November 2 in Albuquerque, New Mexico.

    Kate's right: advocacy for the profession never stops. Find out how to add your voice to the conversation around the NHSC legislation and a host of other important legislative and regulatory issues by visiting APTA's "Take Action" webpage.

    Media Tour Takes APTA's 'ChoosePT' Message Nationwide

    Pain is complicated, and effectively addressing it requires open communication and a true partnership between providers and patients. Sarah Wenger, PT, DPT, believes that physical therapy can support just that type of relationship, and she took that message to TV and radio stations across the United States as part of a recent APTA satellite media tour.

    The "tour" involved linking up with TV and radio stations across the country to arrange for short remote interviews with Wenger, a clinician and educator with extensive experience in working with patients living with chronic pain. The daylong event was held during Pain Awareness month, and provided an opportunity to promote the association's retooled ChoosePT.com consumer site (formerly MoveForwardPT.com), as well as a more broad use of the "ChoosePT" call to action to include a wide range of conditions including pain.

    By the beginning of the tour day on September 18, 28 interviews were booked—17 for television and 11 for radio. The interviews tended to focus on how to address the opioid crisis through better approaches to pain management that involve interprofessional teams, a patient-centered approach, and honest discussions between patients and providers. Wenger emphasized how physical therapy can play an important role in the process. Most of the interviews were broadcast live, but some were recorded for later playback—meaning there's a chance you could hear an interview in the coming days and weeks. Check out this video of a live interview from WTMJ-TV 4, in Milwaukee, for an example.

    The day also included a lengthier interview with Jaqueline Andriakos, health director for Women's Health magazine. That interview, presented as a Facebook Live broadcast, allowed Andriakos and Wenger to discuss at length the more personal, patient-centered relationships physical therapists and physical therapist assistants try to build with their patients.

    In the Women's Health interview, Wenger talked about the importance of receiving a range of care for pain, including physical and mental health care, and how physical therapy's focus on movement fits into the picture.

    "When you're in pain moving is hard, and you end up in this bad relationship with pain where you're scared to move…and you end up doing less and less, and as you do less and less, you can do less," Wenger said. "You get less and less and less healthy, and movement is how you get yourself back to being healthy."

    19 - 09 - 20 ChoosePT Facebook Interview
    Sarah Wenger, PT, DPT, discussed pain management and role of physical therapy with Women's Health magazine in a recent Facebook Live event.

    Time to Act: CMS Proposes Significant 8% Cut to Physical Therapy in 2021

    [Editor’s Note: Response to CMS about the proposed PFS has been strong, and the more comments CMS receives the more likely they are to consider our recommendations. Use this prewritten template letter to add your voice by the September 27 deadline and strengthen our message even more.]

    In this review: APTA's response to a CMS plan to cut Medicare physician fee schedule (PFS) reimbursement for physical therapy providers by 8% beginning in 2021. The reduction for 2021 is included in the proposed 2020 PFS.
    Proposed 2020 Physician Fee Schedule (see table 111, p 1187)
    CMS Fact Sheet
    CMS press release

    The big picture: a proposed 8% cut in Medicare reimbursement for physical therapy providers in 2021
    Deep within the proposed 2020 PFS, CMS reveals a plan that puts Medicare beneficiary access to physical therapy at risk by way of an estimated 8% cut to fee schedule reimbursement in 2021. CMS says the reductions, which affect multiple providers to different extents, are driven by changes to reimbursement formulas for evaluation and management (E/M) services furnished by physicians and some other providers.

    APTA's message to CMS: significant cuts to fee schedule reimbursement for physical therapy providers will put challenging and likely unsustainable financial pressures on physical therapists (PTs), particularly in rural and underserved areas where access is already limited. As more PTs feel this pressure and opt out of treating Medicare beneficiaries—or close their doors altogether—patient access to care will suffer.

    "The changes to reimbursement for office/outpatient E/M codes itself are positive ones and we fully support access to primary care services, but the idea that these changes must be accompanied by deep cuts to other crucial services is outrageous," said Kara Gainer, APTA's director of regulatory affairs. "At a time when our aging population is in need of greater access to physical therapy, with its proven benefits and track record for reducing overall costs, CMS has instead decided to turn its back on the facts and put patients at risk."

    What we're doing—and what you can do (before September 27)
    We're preparing a formal comment letter to CMS, but that's just a part of APTA's efforts. Because the proposal affects multiple providers, from PTs and occupational therapists to clinical social workers, clinical psychologists, ophthalmologists, optometrists, and chiropractors, we're circulating a provider organization sign-on letter objecting to the cuts, and we're working with the American Occupational Therapy Association to develop an additional sign-on letter to be circulated among members of Congress.

    Even more important, we're urging APTA members to bring their individual voices to bear on this issue. We've created a customizable template letter that makes it easy to let CMS know how these proposed cuts will pose a real danger to Medicare beneficiaries and negatively impact PTs' ability to practice under Medicare. Make sure you get your comments to CMS by the September 27 deadline (the template letter includes instructions on how to submit to CMS).

    Tip: this letter is the second template letter we've created in response to the 2020 PFS. The first addresses the problematic physical therapist assistant/occupational therapy assistant coding modifier plan, and is still available for download. If you haven't yet completed and submitted that letter, you can combine it with the letter on the reimbursement cuts.

    What's next
    Deadline for comments is September 27, and the final rule will likely be issued by November 1. In addition to the sign-on letters described above, APTA and several other provider associations will meet with CMS officials in mid-September to share concerns and provide recommendations on a range of issues related to the PFS.

    APTA Launches New ‘Find a PT’ and ‘ChoosePT.com’ Website to Support Consumer Awareness

    Every day, people choose physical therapy for a multitude of reasons, from managing pain to building healthy lifestyle habits. Now APTA's consumer-focused website has a new name—and a new look—to support that reality and help connect patients with physical therapists (PTs) through an enhanced "Find a PT" feature.

    This week, APTA unveiled ChoosePT.com, a consumer website that replaces MoveForwardPT.com, now retired after 10 years. The new site is a best-of-both-worlds combination of 2 of the association's most high-profile and far-reaching initiatives—APTA's popular online source for consumer-oriented health information, now operating under a name that leverages the power of the association's award-winning opioid awareness campaign. The ChoosePT site is expected to receive more than 4 million visitors in 2019, with anticipated increases in the coming years.

    The transition to ChoosePT does not significantly change the content on the former MoveForwardPT site, which still includes information on symptoms and conditions, prevention, and pain management, as well as access to podcasts and videos that deliver powerful messages about the difference physical therapy can make in people’s lives.

    But not everything's the same: The changeover has allowed APTA to make improvements to the site's "Find a PT" directory, an APTA member benefit for physical therapists, that makes it easier for consumers and other providers to filter results by practice focus or specialization.

    The upgraded feature is an opportunity that members shouldn't miss, according to Jason Bellamy, APTA's executive vice president of strategic communications.

    “Millions of people will visit ChoosePT.com this year, and one of their most common destinations will be Find a PT," Bellamy said. "APTA members should ensure their information is up-to-date, and add a headshot to make their profile more appealing. Our message to members is, 'do everything you can to help consumers choose you.'"

    ChoosePT.com is also enhanced by geolocation technologies that, with a user's permission, create an online experience customized to the user's physical location. APTA state chapters that have an active geolocation page—49 to date—can add state-specific information to the ChoosePT site, providing visitors with an additional depth of relevant information.

    Bellamy believes the change to ChoosePT.com is the right move at the right time, with more exciting changes coming around the corner.

    “When we launched our opioid awareness campaign we knew our #ChoosePT message was dynamic enough to extend beyond the safe management of chronic pain,” Bellamy said. “With APTA’s centennial approaching in 2021, and the public awareness opportunities that will provide, this was the perfect time to make that our primary call to action.”

    Want t-shirts with the new ChoosePT logo? They're available here.

    '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.