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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.

    Comments

    • I have been an APTA member for 47 years. I want the association to be more effective as well as realistic in these trying times . Therapists ARE being laid off. Salaries ARE going down. Profession Is being devalued. Glad I am at the end of my career . What are you doing about this??

      Posted by Ilene Larson on 11/22/2019 7:47 PM

    • Solution: See fewer CMS patients and keep the doors open for the other patients. In 1997, when patients couldn’t access treatment due to CMS rules, an overwhelming cry from patients convinced CMS to “alter” the rules. Dr. Brian P. D’Orazio

      Posted by Brian P. D’Orazio on 11/22/2019 9:30 PM

    • I am a DPT and an executive director of a hospital. I am disappointed by what I see in this profession. We are a doctoral level profession, yet we still practice as though we have certificates. We still do not have Medicare direct access, we do not have the ability to order diagnostic tests (X-Rays and MRIs), we cannot do pain injections or even dry needling in NY, and I believe we should be able to order limited pain medication. What are we doing to advance the practice of Physical Therapy commensurate with our expertise level? Many other professions have significantly advanced but PT is standing still. I don't understand it as a member of this community. Alex Hellinger, DPT, MBA

      Posted by Alexander Hellinger -> >OX_BO on 11/23/2019 10:01 AM

    • Well said Alex.

      Posted by John Garzione on 11/26/2019 1:33 PM

    • What are we doing as a profession to support PTAs? The PTAs I know and practice with are expected to perform the same interventions and deliver the same care as their PT counterparts but are not treated with professional respect. Yes, there are things as a PTA they can not do secondary to their states practice act, however, that does limit ones ability to carry out the same interventions that a PT performs with the same level of knowledge and excellent care of that patient. I agree that the physical therapy profession needs more professional respect overall, that needs to start within our own professional organization to unify our voice as a team. This is will allow us as a whole to let our voices be heard to the health care community and CMS. We all got into this profession to help those in need and provide evidence based quality care, somewhere down the line corporations and insurance companies have dictated how we can practice and they have the voice of what is best for the patient. It is time we took our voice back as a unified profession.

      Posted by SG on 11/26/2019 11:47 PM

    • We need to be offering CMS ways to save money or make us more efficient. Our response can be "this is horrible" but if that's it, it'll be ignored. We need to: 1) Ask CMS that if the 15% PTA cut goes into effect, PTAs are allowed to see Medicare patients under general supervision if the state allows it. 2) Eliminate the ability for hospitals to charge facility fees on outpatient therapy services, no exceptions. 3) regulate over utilization of OT services in a skilled nursing setting. 4) regulate over utilization of home health services for orthopedic post-op patients. 5) Automatic decrease in reimbursement rates for physician/chiropractic owned outpatient therapy practices. 6) Automatic lower reimbursement rate if a DME is sold by a therapy practice , but mandate medicaids to accept PTs as DME providers. 7) eliminate any subsidy rural access hospitals get for outpatient therapy services We can give them smart routes to save money and blunt cuts won't be needed. But if the APTA refuses to give ground anywhere we won't be part of the conversation.

      Posted by Simon Hargus on 11/27/2019 11:45 AM

    • So... As the director of an outpatient clinic that employ's a PTA. Should I lower the PTA's salary, decrease their hours, have them not see Medicare patients, or make sure they only treat 10% of the time???? Looks like I am not going to hire that second PTA's in the future. Thank you CMS and Congress. Great job! Over regulation much?

      Posted by Joseph on 11/27/2019 4:00 PM

    • I am PTA. This is been a live changing career, I love it. 90% of my patients are CMS beneficiaries. I am afraid I will loose my job and so many others too. How will we be able to take care of our families? Then the PT will be overwhelmed unable to provide proper care to their patients. This new resolutions should be out in the public eye, because at the end of the day the general public are the ones who will pay the consequences. Is the APTA communicating this with the media?

      Posted by Ana Quinones on 11/27/2019 4:24 PM

    • Alex Hellinger: I couldn't agree more. Thank you for stating this so succinctly.

      Posted by Ralph Simpson, DPT, OCS. LATC on 11/27/2019 6:59 PM

    • I am curious of those who complain about the APTA "not helping the profession" or blame the APTA for today's crappy payment environment, what have you done to help the situation.(Ilene Larson) APTA is a volunteer organization and is only as strong as it's members. As members and professionals it is our responsibility to talk to our government officials to make change. CMS received approx 26,000 letters from members regarding the 2021 payment reductions for 8% and 2022 PTA cuts That means only 26% of our membership tried to help by simply sending an e-mail. and 74% of the membership is riding on the backs of the volunteers that are active. APTA leads the way and tells members what to do, we have representation at all tables of influence and have had meetings with the Secretary of HHS- of which it was APTA volunteers that do the talking. I spent 15 years of my career going to D/C for government advocacy. I annually give to the PAC. Unless you have donated your time, energy and resources (not just dues) to APTA- then the blame for the mess our profession is in, is actually more your fault than the fault of APTA. The APTA and it's active volunteers are the only ones keeping us from loosing more.

      Posted by Amanda Somers on 11/27/2019 7:23 PM

    • Amen, SG. I’ve been PTA for over 20 years, and have never felt supported or respected by the APTA. There has never been a reasonable bridge for PTAs who wanted to become PTs; it’s a political and economic racket. I’ve worked with the same 2 PTs for 15 yrs, and they both treat me as an equal, and both have acknowledged i’m stronger in certain areas than they are. And now, with the modifiers, it looks like we’re going to be thrown under the bus and into extinction. Glad I’m at the end of my career as well. I’m disgusted.

      Posted by Janice Gavin on 11/27/2019 11:14 PM

    • “What are you doing about this??” Let’s see. I am a member of APTA. I donate to PT-PAC and my chapter’s PAC. I continue to build relationships with my legislators. I currently serve in elected positions in my chapter and a section, so I volunteer a lot. “What are we doing to advance the practice of Physical Therapy commensurate with our expertise level?” The question each of us needs to answer is “what am I doing about this”? “Resolve to advocate in your state so that legislators appreciate our contributions to health and wellness. They need information to best serve our communities, and they rely on us to bring it to them. The APTA has built a great infrastructure to help us advocate, and that advocacy must come from each of us. Once you have tried that and appreciate the influence you have in your state, we need to bring that message to Washington. I assure you that there are few things as inspiring as participating in one of APTA’s marches on the capital.” (from DOI: 10.1097/JAT.0000000000000109) Ready to take action? Start at http://www.apta.org/FederalAdvocacy/.

      Posted by James Smith -> @LS\ on 11/28/2019 8:30 AM

    • I thank the above post by SG, we (PTA’s) appreciate your statement. For over a decade, I have even providing Complete Decongestive Treatments for patients whom are diagnosed wit Lymphedema. The appropriate way to perform this treatment requires a full one hour session with each patient. This new rule, most likely, would change my abilities to provide a comprehensive treatment approach and would strain an already under treated population.

      Posted by Óscar Pozzoli, LPTA, Vodder-CLT on 11/28/2019 9:23 AM

    • SG, if we want to promote the value of PTAs then we MUST purse the PTA curriculum as a bachelors degree and not an associates obtained at a community college. One of the biggest issues with PTs, is the rising cost of education and increased student loans. Several PTAs I know have zero debt after school and many programs cater their schooling to allow for part time work. Meanwhile, myself and fellow PTs are $75-150K in debt with low salaries compared to similar medical professionals On top of the degree, PTAs need to be more active in the APTA. I don't think any of the PTAs I know are members of the APTA yet they want the APTA to do it all for them.

      Posted by MKP on 11/28/2019 1:36 PM

    • If PTAs are being seen as non-skilled professionals, enough so to warrant only 85% reimbursement, then why do we continously ignore the education gap? I agree with MKP and SG to an extent. As a profession we need to be pushing for PTAs to become a BA. We need to close some of the skill amd education gap. These 1:1 programs in particular really devalue the profession. To MKP, I will say that while i agree most do not come out with loans, a lot of us did, personally I paid $24,000 for mine. Im still paying it, amd if i lost my job due to these cuts I cant imagine what else i would ever want to do. I love my career, and ive been an APTA member since I was a student. I agree we should be more active in APTA memberships, but the reality is a lot of us cannot afford too, amd those that can feel under valued for reasons such as this budget cut. Im willing to advance my degree to a BA if that is what it takes for patients to get the quality treatment CMS is searching for. I do hope it doesnt come to elimination or severe job cuts for PTAs, because it only creates more chaos in the long run. Companies cant afford to staff 5-20 DPTs depending on the setting in order to tackle the caseload PTAs where seeing, plus now evals and DCs. They will lay PTs off and ask more from the ones they keep, but ultimately less patients will be seen and it is our patients who will suffer yet again at the hands of CMS.

      Posted by SB on 12/1/2019 6:10 PM

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