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  • Donations Now Being Accepted for Florence Relief

    An online giving program established last year to help hurricane victims in Texas, Florida, and Puerto Rico is now focusing its efforts on providing aid to people affected by Hurricane Florence, which recently inflicted billions in damage in the Carolinas.

    Now's your chance to help.

    "Rehab Therapists Give Back," an online giving program designed to provide physical therapists, physical therapist assistants, and other rehabilitation professionals with an opportunity to come together as a unified community to help those in need, is now accepting donations for Florence relief. Accessible through a GlobalGiving website, the initiative allows donors to contribute any amount. Electronic medical records system vendor WebPT and APTA were founding funders of the program.

    Questions? Contact RTGB@webpt.com.

    APTA, Other Health Care Leaders Call for CMS to Rethink Evaluation and Management Payment Plan

    APTA has joined with more than 150 other health care organizations to let the US Centers for Medicare and Medicaid Services (CMS) know that while its "Patients Over Paperwork" efforts are appreciated, one CMS attempt to reduce administrative burdens is likely to result in reduced access to care for some of the sickest Medicare beneficiaries.

    The concerns center around a provision related to evaluation and management (E/M) visits included in the 2019 physician fee schedule rule proposed by CMS over the summer. The change, ostensibly intended to reduce paperwork, would collapse E/M payment rates currently based on a 5-level complexity system for new and established patients into what would amount to a 2-level system—combining levels 1-3 and levels 2-5. CMS acknowledges that the change would result in higher payments for E/M visits at the 1-3 levels while levels 4 and 5 will see reductions based on the 2019 proposed relative value units. However, CMS argues, the reduced paperwork burden would offset the payment drop.

    In a letter sent to CMS last month, APTA and other cosigners praise CMS for its initiative to reduce provider paperwork, but question the wisdom of the E/M plan, arguing that the change would unfairly impact providers who see sicker patients, "ultimately jeopardizing patients' access to care."

    The group also is pushing back against a related plan to reduce payment for multiple services delivered on the same day, something that they argue was already accounted for in previous valuations of the relevant codes.

    As an alternative, the group urges CMS to collaborate with an American Medical Association-sponsored crossdisciplinary work group. That work group has been charged with analyzing E/M coding and developing a better alternative than the one presented by CMS. APTA will be monitoring the work of this group and participating in future meetings.

    APTA Provides CMS With Extensive Comments on Proposed 2019 Medicare Fee Schedule Rule

    APTA delivered a set of comments on the US Centers for Medicare and Medicaid Services' (CMS) proposed 2019 physician fee schedule that were as wide-ranging as the proposal itself, including qualifications on the proposal to extend the Merit-based Incentive Payment System (MIPS) to physical therapists (PT) and clear opposition to a CMS move to lower payment for services provided "in part" by a physical therapist assistant (PTA) or occupational therapy assistant (OTA). Also in the association's comments: recommendations that CMS could strengthen its role in the fight against opioid abuse by better supporting nonpharmacological approaches to pain management, including physical therapy, through payment and education improvements.

    The extensive comments were developed in response to a rule that, if implemented, would include some of the most far-reaching changes in payment and reporting to date, moving PTs into the Quality Payment Program (QPP) and ending functional limitation reporting (FLR) requirements. But that's just 1 facet of the proposal: the rule touches on everything from the use of telehealth to additional current procedural terminology (CPT) codes. APTA's comments addressed both big-picture issues and some of the nuts-and-bolts of the proposal.

    PTs in MIPS: a move that needs to be carefully implemented.
    APTA provided extensive comments to CMS on its proposal to include PTs in QPP—and more specifically in MIPS—characterizing the change as an acknowledgement that PTs "act as integral members of the health care delivery team in outpatient settings."

    APTA's comments outlined a number of concerns and issues, mostly centered on the association's concern that PTs could face serious barriers to participation in MIPS unless CMS provides "certain amnesties." The association also recommends that CMS adopt more flexible approaches when it comes to PTs opting in to MIPS participation, as well as the measures CMS would accept should facility-based PTs be required to participate in MIPS in the future (the current proposed rule only includes PTs in private practice settings).

    APTA also went on record to support a proposed "Physical and Occupational Therapy Specialty Measure Set" within MIPS, and the continued efforts by CMS to eliminate measures that are "topped-out" through high levels of compliance.

    CMS has it all wrong when it comes to adjusting payment for services provided "in part" by a PTA.
    Some of the association's strongest criticism of the proposed rule is aimed at CMS efforts to establish payment differentials, set to go into effect in 2022, based on the extent of a PTA's or OTA’s role in a visit. That criticism is centered on what APTA believes is the impossibility of accurately defining when a PTA or OTA has sufficiently provided services "in part" to trigger a payment differential, and the dangers of creating a rule stating that any PTA involvement constitutes an excuse for lower payment rates.

    While APTA acknowledges that CMS is bound by law to establish a PTA modifier, the association asserts that CMS isn't obligated to go down the definitional rabbit hole associated with pinning down what constitutes care delivered "in whole or in part" by a PTA. In its comments, the association lays out a multipoint case against establishing rules based on terminology that isn't a term of art or statutorily defined, warning that drawing a line on what constitutes "in part" could quickly lead to confusion and loss of access to care, particularly among beneficiaries in rural areas.

    APTA recommends that CMS take more time to reexamine the potential problems and wait until next year's rulemaking to address the "in part" issue. Alternatively, should CMS insist on moving ahead in this rule, the association suggests either of 2 more-straightforward approaches: the so-called "midpoint rule" that would pin 100% reimbursement to whether the majority of services are furnished by the PT; or a "blended rate" approach that splits the fee schedule amount for a code in half and then applies the 100% PT rate to one half, and an 85% rate to the other half, thereby avoiding a single trigger that would shift payment to a lower rate, simply because a PTA provided care "in part."

    Should CMS continue down the PTA payment differential path, APTA strongly recommends CMS exempt rural areas, health professional shortage areas, and medically underserved areas from the proposed policy, due to concerns of how it could affect patient access. Earlier this summer, CMS indicated to APTA and the American Occupational Therapy Association (AOTA) that it did not have the statutory authority to exempt these areas. APTA is investigating whether that's true, and APTA and AOTA also are advocating for Congress to commission a US Government Accountability Office study to examine how access to physical therapy and occupational therapy will be impacted by the payment differential.

    "Given that a [PT] and PTA frequently deliver team-based care, we have serious concerns that requiring the modifier to be applied if any minute of outpatient therapy is delivered by the PTA has serious implications for beneficiary access to care," APTA writes. "Physical therapists and PTAs serve a critical role in the health and vitality of this nation. It is imperative that Medicare beneficiaries continue to have access to high-quality physical therapy services."

    More can be done to fight the opioid crisis if CMS would provide stronger support of (and better payment for) nonpharmacological approaches to pain management.
    APTA recommends that CMS not only step up its promotion of access to team-based nondrug pain management, but that it back up this support with "subregulatory revisions" that could increase patient access through changed payment models. The association also recommends that CMS reduce or eliminate copays for nonpharmacological pain treatments, and that the agency increase efforts to educate both prescribers and the public on the effectiveness and availability of approaches to pain that don't involve the use of opioids.

    Additionally, APTA has a suggestion for providers who continue to prescribe opioids for pain: make a referral to physical therapy a requirement.

    "CMS and other stakeholders must ensure that not only is education for providers enhanced, but that a clear, direct path exists for patients in pain to access all treatment options, including physical therapy," APTA writes. "Given that [the US Centers for Disease Control and Prevention] has concluded that there is insufficient evidence that opioid usage alone improve functional outcomes for those in pain, we recommend that clinicians who prescribe an opioid for pain also must be required to refer a patient to physical therapy."

    Other provisions in the proposed rule didn't escape APTA's notice.
    As is usually the case, the proposed fee schedule covered a lot of regulatory ground. APTA took an equally comprehensive approach in its comments, touching on these additional areas:

    • Barriers to PTs participating in alternative payment models (APMs). While PTs technically are allowed to participate in APMs, APTA argues that from a practical standpoint, the profession is at a disadvantage thanks to barriers thrown up by CMS around the use of certified electronic health record technology (CEHRT). CMS requires at least 75% of all eligible clinicians to use CEHRT—the problem is, PTs have been exempt from "meaningful use" criteria promoting interoperability, and there is a lack of physical therapy-specific CEHRT. The result? "[PTs] are essentially barred from participating in advanced APMs," APTA writes. The association is also advocating to Congress to require CMS to develop physical therapy-specific certification criteria for electronic health record vendors.
    • Payment for technology-based communications. APTA supports CMS efforts to provide payment for physician communications provided via technology and has asked CMS to clarify whether PTs are included in the list of eligible providers. If not, APTA says, CMS should study that possibility and consider expanding provisions in the fut
    • Qualified Clinical Data Registry (QCDR) proposals. Because QCDRs such as APTA's Physical Therapy Outcomes Registry could play such an important role in future value-based care models, the association is paying particular attention to CMS proposals for who gets to be included as a QCDR, and the nature of the relationship between a QCDR and CMS. Specifically, APTA supports a CMS plan to require a QCDR entity to have clinical expertise in medicine and measure development, and it backs the measures selection criteria proposed by CMS. However, the association isn't on board with a CMS proposal that beginning in the 2021 payment year, all approved QCDRs must enter into a licensing agreement with CMS that would allow any QCDR to report on any MIPS measure.
    • Price transparency. In response to a CMS request for perspectives on price transparency, APTA stated its general support for greater transparency but recommended that CMS study state-level initiatives first. The association also cautioned CMS to be careful about how it defines "cost" from a consumer perspective and to avoid divorcing issues of cost from concepts of quality. Additionally, APTA recommended that any price transparency effort be accompanied by extensive public education efforts.

    APTA has additional information and resources on the proposed 2019 physician fee schedule, including fact sheets on the proposal and links to pages with specific information on QPP, MIPS, and APMs. Start with the Medicare Physician Fee Schedule webpage, and sign up for the upcoming webinar, "Everything you need to know about the Quality Payment Program."

    QPP, MIPS, AAPMs: Learn What’s What With New Payment System Webinar Recordings

    The federal rule that would move physical therapists (PTs) into a completely new payment system for Medicare has not yet been finalized, but there's no better time than the present to start learning about the payment environment PTs will likely practice in come January 1, 2019. APTA has you covered.

    Now available: 2 recordings of recent APTA webinars focused on the Centers for Medicare and Medicaid Services' (CMS) Quality Payment Program (QPP), the system that CMS proposes to apply to PTs starting next year. If adopted as described in the 2019 physician fee schedule, QPP would initiate a major shift toward value-based payment for physical therapy under Medicare. QPP incorporates the Merit-based Incentive Payment System (MIPS) and the Alternative Advanced Payment Model (AAPM) programs.

    Both recordings are led by APTA staff members Heather Smith, director of quality, and Kara Gainer, director of regulatory affairs. Smith and Gainer are joined by Barbara Connors, DO, MPH, a chief medical officer for CMS, and Patrick Hamilton, MPH, a CMS health insurance specialist (Hamilton joins the August 23 webinar only). The recordings are free to APTA members.

    What's available:

    August 7, 2018, recording and supporting slide deck on MIPS and its relationship to QPP
    Format: Webinar with accompanying slide deck, followed by question-and-answer session
    Duration: 1 hour (approx)
    Recording: here
    Accompanying slide deck: here

    August 23, 2018, recording and supporting slide deck on QPP, MIPS, and advanced alternative payment models (AAPMs)
    Format: Question-and-answer session on all QPP provisions
    Duration: 1 hour (approx)
    Recording: here
    Related slide deck: here

    [TIP: The August 7 recording is accompanied by a slide presentation. The August 23 session is audio-only but supported by another slide deck not used during the actual webinar. Users of the August 23 materials may find it most helpful to listen to the audio recording first, and then view the slide deck.]

    The recordings are among the first in a series of resources APTA will provide on QPP. After the final rule is out, look for more webinars with CMS staff, APTA Learning Center offerings, and other online resources. Questions? Contact advocacy@apta.org.

    The 2019 physician fee schedule is still a proposed rule, meaning that CMS is accepting comments until September 10. Check out this customizable comment letter template from APTA for an easy way to make your voice heard.

    MedPAC Recommendations for PT Payment Decreases Met With Strong Responses From APTA, Private Practice Section, Alliance

    The Medicare Payment Advisory Commission (MedPAC) may be right in its claim that Medicare Part B payment should be increased for ambulatory evaluation and management (E&M) services, but it's dead wrong when it says that those increases should be paid for by cuts to physical therapy-related payment: that's the message APTA, its Private Practice Section (PPS), and the Alliance for Physical Therapy Quality and Innovation (Alliance) delivered to MedPAC recently.

    The comments were provided in response to MedPAC's 2018 report to Congress on Medicare. In the chapter titled "Rebalancing Medicare's physician fee schedule toward ambulatory evaluation and management services,” MedPAC argues that ambulatory E&M services—defined by MedPAC as office visits, hospital outpatient department visits, visits to patients in other settings such as nursing facilities, and home visits—are "underpriced." That's a problem in need of fixing, MedPAC says, because E&M services "are critical for both primary and specialty care."

    MedPAC's suggestion for how to pay for repriced E&M services, however, isn't exactly a study in nuance. The commission recommends that the increase can be accomplished in a way that won't hurt Medicare's bottom line simply by reducing payment for a wide range of "procedures, images, and tests" that it believes are over-valued—including physical therapy-related services. Depending on the procedure, imaging, or test in question, the recommended cuts are as high as 3.8%.

    In separate letters—1 from APTA alone, and 1 from the 3 organizations jointly—APTA, PPS, and the Alliance write that the goal of adjusting pricing for E&M services is laudable, but when it comes to physical therapy, the logic behind MedPAC's pay-for approach is built on fundamental misunderstandings of the payment code valuation process, the impact of the Multiple Procedure Payment Reduction (MPPR) payment policy, and the true role of the physical therapist (PT) in health care, among other concepts.

    "Our organizations have concerns about the Commission's recommendation to reduce the value of physical therapist services," the combined group letter states. "Such reduction to reimbursement would exacerbate the overall inadequacies in physical therapy reimbursement…and harm the sustainability of the value of the physical therapy profession, and in turn diminish clinical care and outcomes and increase the cost of care to thousands of Americans each and every day."

    At the heart of the MedPAC argument is an assertion that certain non-E&M services have experienced "efficiency gains" over time, making them less complex and time-consuming for providers, and thus ripe for reimbursement reductions. The letters from APTA and the combined group suggest that MedPAC is ignoring important Medicare policies that already address that exact issue—particularly the process for reassessing possibly "misvalued" coding and the MPPR, which requires a reduction in payment when multiple procedures are provided to a patient on the same day of service.

    Essentially, the letters argue that the misvalued code initiative—a process that resulted in revalued codes for many physical therapy-related services in 2017—is already serving as a check against so-called efficiency gains, and that adopting a separate reduction scheme that ignores that process courts disaster.

    "Our organizations have serious concerns that payment policy recommendations which supersede the misvalued codes initiative would not only harm beneficiary accessibility to services offered by physical therapists, but would also compound the payment challenges facing small, medium, and large-sized physical therapy practices," the joint letter states. "To that end, we fail to see where…the Commission assessed how beneficiary access to physical therapy would be impacted should their recommendation be adopted by CMS."

    APTA, PPS, and the Alliance argue that in a similar way, the MPPR already addresses the idea of payment reductions related to efficiencies—a factor also seemingly ignored by MedPAC when it developed its proposal.

    "Should CMS move forward with the Commission's suggestions to further reduce reimbursement for services furnished by physical therapists, the 50% MPPR on the [practice expense] for physical therapy services would duplicate the payment adjustments that MedPAC is recommending to account for the 'efficiencies' in therapy services," the joint letter states. "Moreover, because commercial payers frequently follow CMS's lead regarding code valuations, physical therapists would be subjected to even lower reimbursement from such payers, further challenging their ability to continue to deliver care to patients."

    The APTA letter extends a similar criticism to MedPAC's lack of attention to the potential impact of a proposal to introduce payment differentials for services provided by physical therapist assistants (PTAs), asserting that that change alone could result in reductions in care, only to be made worse through adopting the MedPAC recommendations.

    Beyond those failures in analysis, the MedPAC proposal also includes a more general lack of awareness of the value of physical therapy—both as a key player in value-based care, and an important tool in pain management in ways that help reduce the severity of the opioid crisis in the United States.

    "Moving forward, it is imperative that [the US Centers for Medicare and Medicaid Services] acknowledge the important role physical therapists play in prevention and treatment of acute and chronic pain," the joint letter states. "MedPAC's proposal to reduce reimbursement for physical therapy services at a time when benefit design and reimbursement models should support early access to nonpharmacological interventions—including physical therapy—for the primary care of pain conditions is short-sighted and unfounded."

    The APTA letter also characterizes the MedPAC proposal as "contradictory to the commission's current efforts to incentivize value over volume."

    "Reducing reimbursement for highly sought-after (and consequently, highly utilized) services will force providers to find ways to increase the volume of services; thus, in future years, the commission will be prompted to recommend greater reimbursement recommendations, and so forth, resulting in a vicious, circuitous cycle that may encourage fraud, waste, and abuse," APTA writes. "We recommend the commission examine payment policies that will incentivize providers, including PTs, to transition to a value-based payment system, as opposed to putting forth proposals that promote the delivery of unnecessary interventions."

    The APTA letter also argues that there's a solid case to be made for including physical therapy among the E&M services in need of repricing, asserting that PTs meet MedPAC's definition of E&M services as those provided by clinicians to diagnose and manage patients' chronic conditions, treat acute illnesses, develop care plans, coordinate care across providers and settings, discuss patient preferences, and engage in shared decision-making with patients. According to APTA, that's what PTs do, too.

    "PTs, like most health professionals, are educated to provide services in the health services delivery environment," APTA writes. "PTs are also uniquely educated and trained to adapt health care recommendations to the community environment where individuals live, work, and play. This knowledge and ability enables PTs to adapt medical recommendations to specific environments, to meaningfully interpret health recommendations, to help individuals modify their health behaviors, and to ensure that clinical and community services are integrated, available, and mutually reinforcing."

    What's the Latest at CMS? Your 2018 Guide to Recent Proposed and Final CMS Rules

    The Centers for Medicare and Medicaid Services (CMS) spent its spring and summer issuing proposed and final rules, some of which contain major shifts in the payment and reporting systems for physical therapists (PTs) in private practice, as well as those working in skilled nursing facilities (SNFs) and home health settings.

    Here's a quick guide to the status of some of these rules and resources available from APTA—including an August 23 webinar, cohosted by APTA and CMS, focused on the proposed transition of physical therapists to the Quality Payment Program (QPP) beginning in 2019 (12:00 pm–1:00 pm, ET).

    Medicare Physician Fee Schedule (MPFS)
    Status: Proposed; comments due September 10
    Resources:CMS fact sheet, PT in Motion News series (part 1, part 2, part 3), APTA fact sheets (part 1, part 2, part 3); recorded webinar (from August 7); August 23 webinar

    It's hard to overstate the magnitude of the changes that will be faced by PTs in private practice who furnish services under Medicare if the proposed fee schedule is adopted as written. Basically, these PTs would be subject to an entirely new payment system, known as the Quality Payment Program—a significant shift toward value-based care models. At the same time, the unpopular Functional Limitation Reporting system would go away—thanks in part to APTA’s continued advocacy against it.

    Under QPP, qualifying PTs would have a choice of participating in the Merit-based Incentive Payment System (MIPS) or—if available to them—an advanced alternative payment model (AAPM). MIPS requires reporting in 4 performance categories (PTs in 2019 will be required to report under only 2 categories: quality and improvement activities), with providers earning points in each category. An annual MIPS score would determine whether the providers earn a payment incentive, remain neutral in payment, or are subject to a penalty. Several of the data points must be reported electronically through certified electronic health record (her) 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.

    The AAPM-based QPP option allows participants to be exempted from MIPS and opens up the possibility of a 5% annual payment bonus (beginning in 2021 for the 2019 performance year) in addition to payment adjustments up or down; however, certain patient or payment thresholds must be met. The proposed rule also includes an option for QPP participation through Medicare Advantage.

    But that's only 1 element of the fee schedule. The proposal also contains provisions around coding for services furnished by physical therapist assistants (PTAs), and a slight boost in payment. And yes, CMS intends to continue use of the KX modifier for claims that exceed an annual dollar threshold (currently $2,010 for physical therapy and speech-language pathology services combined).

    [Editor's note: don't miss the August 23 live webinar on QPP, MIPS, and Advanced APMs hosted by CMS and APTA.]

    Home Health Prospective Payment System (HH PPS)
    Status: Proposed; comments due August 31
    Resources: CMS fact sheet; PT in Motion News coverage

    Another big change in the works: CMS wants to adopt an entirely new payment methodology for home health, known as the Patient Driven Groupings Model (PDGM). The new system, mandated by the Bipartisan Budget Act of 2018, lays out a new payment landscape through changes that include shifting care from 60-day to 30-day episodes, removing therapy service-use thresholds from case-mix parameters, and establishing a 5-parameter system that plays into payment determinations.

    Under the proposed rule, payment for 30-day episodes would be tied to 1 of 216 payment groupings that reflect the patient's status related to 5 major factors: timing, admission source, clinical group, function level, and comorbidities. The proposed rule also includes changes to certifying and recertifying patient eligibility for continued home health care; an allowance for home health agencies to report the cost of remote patient monitoring; and a transition toward payment for home infusion therapy. The changes proposed by CMS would result in an estimated 2.1% increase in payments in 2019, or about $400 million.

    Skilled Nursing Facility Prospective Payment System (SNF PPS)
    Status: Final, effective October 1, 2018
    Resources: CMS fact sheet; PT in Motion News coverage; APTA fact sheet

    SNFs were not exempt from a major payment revamp, either: effective FY 2020—which begins October 1, 2019—CMS will do away with the Resource Utilization Groups Version IV (RUG-IV) process and implement an entirely new system called the Patient-Driven Payment Model (PDPM). The model bases payments on a resident's classification among 5 components including physical therapy and uses case-mix groupings as multipliers to establish a per-diem rate. The rule also includes a 2.4% payment increase for FY 2019.

    Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS)
    Status: Final, effective October 1, 2018
    Resources:CMS fact sheet; PT in Motion News coverage; APTA fact sheet

    For PTs, the biggest news here is that CMS is dropping the Functional Independence Measure instrument from the IRF-PAI, effective FY 2020—which begins October 1, 2019—and eliminating reporting requirements around methicillin resistant staph aureus (MRSA) infection and the percent of patients assessed and given the seasonal flu vaccine. CMS also will allow physicians to lead team meetings remotely and will evaluate that change with an eye toward expanding the flexibility to other team members.

    Inpatient Prospective Payment System (IPPS)
    Status: Final, effective October 1, 2018
    Resources: CMS fact sheet; PT in Motion News coverage

    CMS is upping payment to acute care hospitals (ACHs) to the tune of some $4 billion and reducing reporting requirements. The final rule drops 40 quality-reporting measures for hospitals involved in Medicare and Medicaid EHR incentive programs, but it backs away from a proposal to eliminate 4 measures of patient safety and retools (and renames) the EHR Program, now called the "Promoting Interoperability Program." Long-term care hospitals (LTCHs) will see an estimated 0.1% drop in payment and an end to a CMS policy that pays LTCHs at a rate comparable to an ACH if an LTCH admits more than 25% of its patients from a single ACH. That program was suspended in 2018—the rule makes the change permanent.

    Outpatient Prospective Payment System (OPPS)
    Status: Proposed, comments due by September 24
    Resources:CMS fact sheet; PT in Motion News coverage 

    Should Medicare reimburse outpatient facilities owned by hospitals at higher rates than it does independent providers' facilities? CMS doesn't think so. The proposed rule would eliminate the payment differential that favors "off campus" hospital-owned facilities, resulting in an estimated $760 million in savings. Those savings would help to offset an overall payment increase of $4.9 billion—a 1.25% increase. The proposed rule also ups payment for ambulatory surgical center (ASC) payment by 2% and establishes separate payment for nonopioid pain management drugs that function as a supply when used in an ASC surgical procedure.

    Short-Term, Limited-Duration Health Plans
    Status: Final, effective October 2, 2018
    Resources: CMS Fact Sheet; PT in Motion News coverage

    Not really a CMS rule, but something worthy of attention. The US Department of Health and Human Services has expanded the use of short-term, limited duration health plans that were originally intended to provide consumers with temporary gap coverage after changing jobs. Now, consumers can enroll in short term plans for just under a year, with an option to renew for up to 3 years. Short-term plans differ from typical Affordable Care Act (ACA) marketplace health plans in that they do not have to cover essential health benefits or ensure certain consumer protections required by the ACA, including those related to preexisting conditions and continued coverage.

    A Stark Reality: APTA Continues Efforts to Shore Up Self-Referral Law

    As the US Centers for Medicare and Medicaid Services (CMS), lawmakers, and others continue to press for more value-based approaches to care, attention has turned to a law that bars physicians from referring Medicare patients to services in which the physician has a financial interest, aka "self-referral." CMS has hinted that the prohibition, known as the Stark law, may interfere with the adoption of new, more integrated models of care, and a US House of Representatives subcommittee held a hearing on "modernizing" the law, perhaps through loosening up restrictions. APTA argues that at least part of the reform efforts should be aimed at eliminating exceptions as a way to increase value-based care opportunities.

    Recently, APTA staff were on Capitol Hill to encourage legislators and their staff to take a careful approach to decisions about the Stark law, which was the subject of a July 17 House Ways and Means Health Subcommittee hearing. During that hearing, legislators were weighing the law's effect on the ability to create alternative payment models (APMs)—systems that often seek to streamline and coordinate entire episodes of care. The hearing echoed a recent CMS request for information from the public on the Stark law, and discussed whether there is a need for "revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law."

    In comments provided to the House subcommittee, the association argues that a reformed Stark law with fewer loopholes could actually promote the growth of value-based care by leveling the playing field for physical therapists (PTs).

    As APTA explains in its comments, the current version of the Stark law includes an exception that allows physicians to self-refer for so-called "in-office ancillary services" (IOAS) that include physical therapy. That exception winds up hurting the development of APMs because it "fail[s] to promote collaboration with small- and medium-sized physical therapy and nonphysician practices," APTA writes.

    "Until [the US Department of Health and Human Services] creates a more level playing field between these different types of providers, physical therapists will be unable to meaningfully participate in Medicare and Medicaid APMs, despite their desire to do so, potentially impeding patient freedom of choice and access to the highest-quality care," the comment letter states.

    The association isn't alone in its commitment to eliminating Stark law loopholes. In 2017, APTA joined with the Alliance for Integrity in Medicare to support a bill in the House of Representatives that seeks to eliminate the IOAS exemptions. That bill, also supported by AARP, has not been scheduled for House committee review

    "We see the recent subcommittee meeting as a chance to highlight the need for more opportunities for physical therapist to participate in alternative payment models, all while protecting patient choice, increasing transparency, and strengthening access," said Justin Elliott, APTA's vice president of government affairs. "Effective value-based care is important. Eliminating conflicts of interest in health care is important. There's no reason why the two can't coexist."

    APTA will share that sentiment with CMS when it delivers the association's response to the CMS request for information (RFI) on the Stark law. The CMS call for feedback is largely focused on how the Stark law could be weakened through the creation of more exceptions or other tweaks, all in the name of promoting more coordinated care models. APTA is coordinating with the APTA Private Practice Section to draft comments by the August 24 deadline.

    The association also has developed a template letter that allows individuals to create a customized-but-consistent response to the CMS request (scroll down the webpage to the second bullet point under "APTA's Current Regulatory Advocacy Efforts).

    APTA is a strong supporter of easing unnecessary regulatory burdens on providers, but CMS and Congress must proceed with caution," said Kara Gainer, APTA's director of regulatory affairs. "We are urging CMS to think very carefully about the unintended consequences of making any changes that increase self-referral. A weaker Stark law could actually impede the transition to value-based care and worsen the patient experience in the process."

    2018 State Policy and Payment Form Offers a Packed Agenda

    Issues that directly affect physical therapists (PTs), physical therapist assistants (PTAs), and society as a whole—population health, the opioid crisis, innovative delivery models, and much more—will be front and center at the 2018 APTA State Policy and Payment Forum. Registrations are now open for this important members-only gathering, to be held September 15–16 at the Westin Crown Center in Kansas City, Missouri.

    The forum is designed to increase PT and PTA involvement in and knowledge of state legislative and payment issues that have an impact on the practice of physical therapy, and to improve legislative, regulatory, and payment advocacy efforts at the state level.

    In addition to presentations on current advocacy efforts in the states, the forum will include information on federal regulatory issues; a presentation on state telehealth policy; and breakout sessions on state issues in pediatrics, value driving payment and contracting, and the physical therapy licensure compact. The event also includes a workshop for legislative chairs and lobbyists, and another aimed at payment chairs.

    Registration is online-only and is open through August 17—no onsite registrations will be offered. Visit the forum registration page to sign up and learn more about the event.

    Tiered Coding for PT Evaluations: New APTA Podcast Series Answers Common Questions

    As the payment landscape for 2019 comes into focus, it's becoming clear that physical therapists (PTs) will continue coding evaluations according to a 3-tiered system based on patient complexity. It's also clear that for now, at least, Medicare will not be using a tiered payment system, even as some commercial payers and state Medicaid plans adopt systems that reflect the complexity levels. Through it all, APTA continues to offer resources that help to reinforce accurate and consistent coding.

    CMS has indicated that its flat reimbursement policy, opposed by APTA from the start, will allow the agency to evaluate the distribution of utilization of the tiered codes in order to better determine the payment model. That distribution is beginning to come into focus: APTA research into nearly 4 million evaluations billed by providers across settings has revealed that 47% of evaluations were billed in the low-complexity category, 45% in the moderate-complexity category, and 8% in the high-complexity category.

    "At this point in time we have a sampling of baseline data that reflects practice in the first year of the tiered codes," said Alice Bell, APTA senior payment specialist. "CMS is also looking at this data and has indicated that they feel it will take 2 years of data to have an accurate representation. That means it's important that coding remain accurate and consistent."

    In its latest efforts to help underscore the importance of continued accurate coding, APTA produced a series of free podcasts on the CPT evaluation codes. The 5-part series covers a general overview of the coding change and addresses common questions related to determining levels of stability, documenting elements, the relationship of examination time to code selection, and coding in reevaluation. With episodes ranging from 5 to 8 minutes in length, the individual podcasts are convenient for quick listens on the go or during breaks at the clinic.

    "APTA is committed to supporting physical therapists through this transition to tiered coding in order to ensure that code selection truly reflects the level of complexity of the evaluation," Bell said. "Before we see further changes in reimbursement based on the tiered codes we want to make sure therapists have the tools and resources necessary to make the appropriate code selection. Accuracy in coding is critical if we are to make a compelling case for achieving our long-term goal of establishing reimbursement rates that truly reflect patient complexity."

    CMS to Host Fee Schedule Webinar for APTA Members

    If the 2019 physician fee schedule is adopted as proposed by the Centers for Medicare and Medicaid Services (CMS), physical therapists (PTs) will need to get up to speed quickly. Now CMS is offering APTA members a head start.

    On August 7 from 12:00 noon to 1:00 pm ET, CMS will host a live webinar on the Quality Payment Program (QPP), the value-based payment model that will require PT participation beginning in 2019 under the proposed fee schedule. Presenters will focus on the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPMs), and offer a brief question-and-answer session.

    The webinar is free, but space is limited. Interested APTA members are encouraged to complete the online registration (APTA login required) as early as possible. For members unable to join the live presentation, a recording will be posted on the APTA MIPS webpage at a later date.

    What's the proposed 2019 fee schedule all about? This 3-part series from PT in Motion News takes a look at MIPS, AAPMs, and more (part 1, part 2, part 3).