Friday, November 22, 2019 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.