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  • The 2019 Fee Schedule, Part 1: 5 Things You Need to Know About What MIPS Might Look Like for PTs Next Year

    Part 1 of a 3-part series on the proposed 2019 Medicare physician fee schedule. This installment: how the Merit-based Incentive Payment System (MIPS) would play out for PTs and PTAs under the proposal.

    Beginning in 2019, physical therapists (PTs) and physical therapist assistants (PTAs) could be facing one of the most dramatic shifts toward value-based payment in Medicare, all courtesy of the US Centers for Medicare and Medicaid Services (CMS) and its proposed 2019 physician fee schedule. The biggest change: a requirement that eligible PTs participate in the CMS Quality Payment Program, where MIPS looms large.

    What is MIPS? Basically it's a reporting system that tracks 4 provider performance categories and awards performance points to produce a total annual MIPS score. That score in turn determines whether the providers earn a payment incentive, remain neutral in payment, or are subject to a penalty. Physicians and a few other providers have been participating in MIPS for the past 3 years at better-than-expected rates—now PTs, occupational therapists, social workers, and clinical psychologists may be added to the list of MIPS reporters. (Editor's note: this article from a 2017 issue of PT in Motion magazine lays out the fundamentals of the program; in addition, earlier this year the association produced a podcast series on value-based care that covers MIPS and other issues.)

    With the publication of its proposed 2019 physician fee schedule, CMS provided the first glimpse at how the system would be rolled out and applied to PTs. Here are 5 things to know about what CMS is proposing:

    1. Initially, PTs will be assessed on only 2 of the 4 MIPS categories.
    Although physicians participating in MIPS must report on all 4 MIPS categories—quality, promoting interoperability, clinical improvement activities, and cost—PTs will be assessed only on quality and clinical improvement activities, at least in 2019. The cost and interoperability categories will be "zero-weighted," according to the proposed rule.

    2. There are criteria for mandatory participation, and not all PTs or practices will qualify.
    MIPS has a so-called "low-volume threshold" that essentially exempts providers from reporting unless they meet 3 annual criteria: allowed charges under Medicare Part B for professional services of $90,000 or more; more than 200 Medicare Part B-enrolled individuals provided covered professional services; and more than 200 covered professional services provided to Part B enrollees. Remember, all 3 elements must be met: given that most PTs in private practice provide more than 200 covered professional services in a year, mandatory participation in MIPS will probably boil down to the total charges and patient numbers criteria.

    3. MIPS applies to PTs in private practice only—and group practices are assessed as a whole.
    For now, MIPS will be limited to PTs in a private practice, but it's important to understand that, unlike the physician quality reporting system (PQRS) that MIPS replaces, group practices will also be assessed for reporting as a whole. That means even PTs in group practices who do not exceed the low-volume threshold level as an individual provider will be required to participate at the group level if the group itself is participating in MIPS and, combined, exceeds the low-volume threshold.

    4. You could still participate in MIPS voluntarily (and it may be a good way to understand the system before you're required to report).
    Beginning in 2019, PTs will have 2 ways to participate in MIPS by choice. First, those who meet 1 or 2 of the 3 participation criteria listed in tip 2 will be allowed to opt in to MIPS. Providers who choose to opt in would do so on an annual basis, and once they make that election they would be treated like a MIPS participant, with the ability to earn a payment incentive, remain neutral in payment, or receive a penalty based on their performance. Second, as in previous years, voluntary participation in MIPS by PTs who aren't required to do so would remain an option, with no payment adjustments associated with participation. APTA encourages voluntary participation in MIPS as a good way to get familiar with a system that seems likely to grow in its reach.

    5. Practices of more than 15 eligible clinicians would need to report to MIPS electronically beginning in 2019.
    Claims-based reporting would be limited under MIPS. Instead, electronic reporting via certified electronic health records (EHRs) or registries would be mandated for practices of 15 or more clinicians (not 15 or more PTs, but all MIPS-eligible providers in the practice). Claims-based reporting would still be an option for solo practitioners and smaller practices, but, again, it's important to understand that mandated electronic reporting is likely to be extended to ever-smaller practices in the coming years, so any providers not yet required to report electronically would be well-advised to start learning about and investing in technology now. APTA is helping to make MIPS reporting easier through its Physical Therapy Outcomes Registry, which has been recognized by CMS as a qualified path for electronic reporting.

    Up next in the series: it's not just about MIPS—a look at other ways PTs could participate in the CMS Quality Payment Program.

    Get ready for the future of PT payment: APTA offers a wide range of online resources on value-based care in general and MIPS in particular, including a readiness self-assessment quiz, a podcast series, a video, and more. Additionally, APTA's Physical Therapy Outcomes Registry has earned "qualified clinical data registry" status from CMS, meaning that PTs who participate in MIPS can use the PTOR to submit their data to CMS.



      Posted by JASMINE on 7/26/2018 10:31 AM

    • This is a long time in coming and badly needed if we are to save the Medicare program. My only wish is that it is rolled out sooner and with more incentives/penalties.

      Posted by Kay A Scanlon on 8/1/2018 8:05 AM

    • My business partner and I opened our clinic in January 2018. We are the only 2 physical therapists, and there is no way we'd see 200 different Medicare patients in a year. We were told if we don't qualify for MIPs then the fee schedule will not change after 2020 and we'd receive the same reimbursement year after year. We strive to provide the best, functional care for all of our patients and this will severely affect the small clinics and clinics in rural areas as well.

      Posted by Melissa Pietraszewski -> AGSa>F on 8/9/2018 10:07 AM

    • Everyone is saying that PTOR will be free for the 1st 2 years for new users. Is this true?? I cannot find anything on the APTA or PTOR website. HELPPPP!!! Small practice here. 1 clinic, 4 clinicians.

      Posted by Marie on 11/21/2018 6:47 PM

    • Hi Marie: please contact the Registry at registry@apta.org so we can discuss options with you!

      Posted by APTA Staff on 11/26/2018 8:21 AM

    • Where is information about the size of the payment incentives?

      Posted by Susannah on 12/27/2018 5:03 PM

    • I believe your 3 annual criteria has an error; this is what it should say 3 annual criteria: allowed charges under Medicare Part B for professional services of $90,000 or LESS;LESS than 200 Medicare Part B-enrolled individuals provided covered professional services; and LESS than 200 covered professional services provided to Part B enrollees.

      Posted by Suzanne Johnson on 12/31/2018 10:42 AM

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