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  • Humana Adopts PTA Coding System, Anticipates Payment Differential Beginning in 2022

    Commercial health insurance giant Humana has announced that it's falling in line with rules from the Centers for Medicare and Medicaid Services designed to establish an 85% payment differential for therapy services delivered "in whole or in part" by a PTA or occupational therapy assistant. Consistent with CMS, Humana is requiring use of code modifiers in 2020, with no changes to payment until 2022.

    The new system, which establishes a code modifier ("CQ" for PTAs and "CO" for OTAs) began on January 1 for Medicare Part B payments. The new approach was triggered by federal law that mandated the creation of a way to denote the volume of physical therapy and occupational therapy services delivered by PTAs or OTAs, and then create a payment differential for those services. In its announcement, Humana states that its policy will mirror the CMS rule, "as applicable in the Federal Register and relevant CMS guidance." Like CMS, Humana also is requiring the modifier on all applicable claims submitted for services delivered beginning January 1, 2020.

    While the modifier system won't affect payment immediately, both CMS and Humana have stated that they intend to reimburse at 85% of the physician fee schedule for services delivered "in whole or part" by a PTA or OTA beginning in 2022.

    Recognizing that CMS was legally bound to establish a differential system, APTA fought initial drafts of the rule that were needlessly burdensome and seemed to ignore the realities of PT and PTA practice. The final rule included several modifications either suggested or supported by APTA, and the association continues to advocate for changes to the system.

    APTA will meet with Humana representatives to address the adoption of the modifiers and the payment differential and will work to limit the adoption of this policy by other payers.

    APTA offers a quick guide to using the PTA modifier and provides more resources on the differential at the APTA fee schedule webpage.

    Comments

    • BCBS State Plan is now stating that only PTs can deliver treatment to their patients. Can they actually mandate that? It’s crazy I’m a veteran PTA with 27 years experience and loads of continuing education yet in order to get insurance payment the patient has to be treated by PT. Half the time I am demonstrating skilled and learned techniques to inexperienced PTs I work with. I am worried about the PT profession in general at this point. Personal trainers are beginning to be utilized for healthcare over PT/PTAs. My question, can the insurance deny payment or reimbursement if patient treated by PTA?

      Posted by Teresa Tanner on 1/22/2020 3:24 PM

    • I think this is terrible. Not surprising to see commercial.insurance companies do this. My heart go out to all the well trained professional PTA's how this affects their future.

      Posted by Terry Trundle PTA LAT ATC on 1/22/2020 4:19 PM

    • Justin Moore and Sharon Dunn again wowing with such great leadership. You guys are really bad. Hopefully students will stop eating out of APTA'S hand, and understand the reality in front of them.

      Posted by Taylor on 1/22/2020 8:57 PM

    • Reduce patient premiums, if you want to cut services they so desperately need. They will need their money to pay out for more hospital stays.

      Posted by Linda Schob on 1/23/2020 8:22 AM

    • Thanks for allowing our profession as PTAs to take a plummet. This is ultimately going to have a burden on patient access and its because of YOU, APTA. Thanks for nothing!!!

      Posted by Mike on 1/23/2020 9:31 AM

    • Having been a PTA for 10 years, I have never felt represented by the APTA. I was a member while in school and out of school, but things never got better. I do not see this profession getting any better. My license expires in a few months. I think it is time to move on.

      Posted by Jason B on 1/23/2020 10:42 AM

    • At least let us see Medicare patients under general supervision if they do the 15% cut and better yet start that now. That should be easy first step for APTA to negotiate because the comparison was with PA/NP and they are allowed to do see patients without a supervising doc on site. Come on APTA. **This**is**not**that**hard** Also how many outpatient speech places does everyone see out there? Not that many. Don't kid yourselves, the cost getting a DPT (the salary they need) + PTAs not being financially viable + declining reimbursement rates is not a world where you don't see massive closings in the outpatient PT space.

      Posted by Simon Hargus on 1/23/2020 11:33 AM

    • This is an absolute joke to have been devalued so much and so abruptly. Talk about putting all your eggs in one basket. Our PTA license and training is useless outside of this field... PT's will be forced to see the patient's in lieu of lesser payment obtained when a PTA performs the treatment. All I have heard for years is job growth projections, baby boomers, 10,000 + medicare-eligible every day. Now due to PDPM and PDGM the case loads are dropping significantly. PT/OT's will gradually start seeing the regular visits over assistants and we will be phased out. I always knew this was to good to be true.

      Posted by Joseph Smith on 1/23/2020 11:36 AM

    • Well since APTA is having a difficult time saving the PTAs career. Maybe they can give insight and advice on to what the heck we're all going to do with our pointless degrees once we're unemployed. I will not be spending another 100,000 dollars to go to DPT school. Quite frankly it's not worth the student loans and if they only want PTs seeing patients then facilities will have to pay PTs less to even be profitable in the first place.

      Posted by Chelsea Perrotta on 1/23/2020 9:46 PM

    • In my 10 years as a PTA in this field I would say I never saw this coming. I just know that a RPT can’t do all the work by themselves just like a physician can’t either, that’s why they have assistants. This is most definitely going to put a shortage on therapist because not everyone have the drive to go to school to become a DPT which takes 6-8 years. I think if they are going to try to weed out the PTA, then they need to get rid of the degree all together. It’s wrong to have people going to school for a PTA and can’t even get a job when they finish school.

      Posted by Octavia Spiller on 1/24/2020 9:58 PM

    • I think the first line of action for the APTA is to be honest to these thousands of students who are about to be blindsided. Stop accrediting these schools pumping out all these grads. This profession is plummeting and its criminal for these schools to continue taking money from them. At least allow the students to know that PTAs will not be treating as some insurances wont pay. If they still want to go for it then go ahead. I dont understand why the insurances care.. PTAs are cheaper anyway. What facilities are really going to pay a PT/OT to do all yhe treats? Too expensive. We are cist effective and time efficient. This is obsurd. And I agree with the comments on what are we going to do with our degrees?? Some of us just got stuck with student loans and no jobs. Now we have to go back and spend more money to get another degree. Does the APTA care?? Whats your solution? We want to know how or if your going to help us or are we screwed? Its time to own up! And let these students know for goodness sakes!!!!!!

      Posted by Becca Reece on 1/25/2020 1:19 PM

    • Shame on the APTA for not representing the PTA’s! That is deplorable......

      Posted by Mike on 1/25/2020 6:58 PM

    • Its really just another way for insurance to pay less. Thats what is always about. Not the care provided. The irony is most patients think the care provided by PTA's and COTA's is better than the care they receive from PT's and OT's because insurance demands so much paperwork time from PT's and OT's. When i was in PTA school in 1992, we went to something at the Rock Eagle Boy Scout camp hosted by Pearl somebody or Somebody Pearl. She provided a big drink fest and she spouted for days how she would get rid of PTA's altogether. I cried thinking I was about to graduated from something and still be unemployed. It was all PT and PTA students. I'm a PTA, and along with many others, we work damn hard. This to shall pass

      Posted by Marla Brinson on 1/26/2020 5:42 PM

    • ACOTE pkease stop taking money to open schools. I have been a COT/A since 1992. I lived through PPS changes & just about every administration’s take on health care. There are many fine OT/PT assistants out there that are now jobless. We lost our jobs, cars, housing, etc. we can’t afford to aupport the AOTA, ACOTE any more. Can you please stand & fight for us. Many of us feel betrayed. This may turn around 1 day when see sick/injured people not getting the treatment & services they deserve.

      Posted by Patricia Kerlin on 2/11/2020 7:10 PM

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