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  • PTAs, Direct Access, Plans of Care, and More: APTA and Components Press for Changes

    If CMS really wants to put "patients over paperwork" in physical therapy, it could start by allowing PTAs to provide maintenance care across settings and easing PTA supervision requirements. And while it's at it, the agency could abandon outmoded approval requirements for plans of care, increase direct access to PTs, and expand PTs' ability to bill for care provided by a qualified substitute when the primary PT is unavailable. Those are just a few of the options that APTA and two of its components put on the table in recent comment letters.

    Ask and CMS shall receive
    The most recent comment letters — from APTA, the APTA Academy of Geriatric Physical Therapy, and the association's Home Health Section — were produced in response to a call from CMS to provide recommendations about eliminating Medicare regulations that require more stringent supervision than is required in existing state scope of practice laws, or that limit health professionals from practicing at the top of their license. CMS also asked for input on ways to strengthen its "patients over paperwork" initiative intended to ease administrative burden on health care providers as it relates to the specific areas in regulation that restrict providers from practicing to the full extent of their education and training.

    APTA took up CMS on its offer, as it typically does (in 2019 APTA submitted approximately 100 comment letters on proposed federal regulations and policies) including the most recent invitation to comment specifically on how scope of practice issues might be improved to make the system less cumbersome. As with several past calls for comment, APTA was joined by association components who have particular interest in the subject at hand. The result: multiple perspectives but a unified voice on how things could be improved.

    Opening possibilities for PTAs
    A common thread between the recommendations involved PTAs — specifically, allowing PTAs working in private practice to move to a "general supervision" model and expanding the PTA's ability to provide maintenance therapy across settings.

    Current Medicare regulations say that PTAs working in all settings except private practice may receive "general supervision" from a qualified PT, which doesn't require the PT to always be physically present. State laws can impose more stringent requirements that must be followed, of course, but the reality is that 44 states currently take the general supervision route.

    Private practice, however, is a different matter: In that setting, CMS stipulates onsite supervision, a rule that APTA believes severely limits practices and results in delays in care "that may be harmful to functional outcomes and quality of life." APTA and the geriatrics academy both press for CMS to relax the requirement.

    The letters from APTA and the Academy of Geriatric Physical Therapy also push for an expanded role for PTAs related to maintenance therapy under Medicare Part B. Right now, PTAs may furnish skilled maintenance therapy in skilled nursing facilities — SNFs — and home health settings under Medicare Part A only, and they are prohibited from providing maintenance therapy in private practice settings. the submitted letters assert that PTs are perfectly capable of making a determination as to whether it's clinically appropriate for a PTA to provide maintenance therapy, and that leveling the requirements "would provide regulatory alignment and afford providers more latitude in resource utilization."

    Getting real with plans of care and direct access
    PTAs weren't the only focus of the letters: Clunky provisions around whether and how PTs create plans of care and needless limits on direct access to PT services both received attention from APTA and the two components in various combinations.

    Both APTA and the Home Health Section argued for changes that would allow PTs to establish home health physical therapy plans of care, as they are allowed to do in outpatient settings. In its letter, the Home Health Section writes that PTs "are unnecessarily burdened by asking physicians to establish and review therapy plans of care in home health, and physicians are unnecessarily burdened by establishing and reviewing those same plans of care."

    Another provision that prevents PTs from practicing at the top of their license, according to APTA and the Academy of Geriatrics Physical Therapy: so-called "certification requirements" for plans of care that gum up care delivery. Under current rules, outpatient plans of care for therapy must be accompanied by a physician or qualified nonphysician practitioner signature, a requirement that frequently leads to delays in providing needed therapy while the PT waits for (and sometimes repeatedly reminds) the physician to sign off.

    Both letters describe the certification requirement as an "untenable" administrative burden for PTs, with APTA writing that "[PTs] and other therapy providers should not be held responsible and possibly subject to medical review due to a physician's inaction."

    Both letters also express that it's high time for CMS to extend direct access to PTs in hospitals, including critical-access hospitals, and SNFs.

    "Medicare beneficiaries [in these settings] who require rehabilitation frequently are admitted to a hospital but then must 'sit and wait' until a practitioner can sign an order," APTA writes. "While hospitals are showing a statistically significant decrease in specific health care-associated infections, the evidence regarding hospital-associated disability is mounting, clearly indicating the medical necessity of early and progressive mobilization during the acute period of the episode of care."

    These dangers could be avoided, both letters argue, if CMS would permit stronger direct access provisions in these settings, with the letter from the Academy of Geriatric Physical Therapy stating that "direct access increases choice in the selection of a health care professional, offers access to less expensive and more timely care, and is a simple yet extremely effective way to meet the goals of increased access and cost containment."

    Expanding locum tenens
    While it's technically true that CMS affords PTs locum tenens — the provision that allows a provider to retain a substitute when she or he is absent because of illness, vacation, pregnancy, or continuing education and still receive payment — the allowance is currently limited to specific geographic areas that have been identified as having gaps or shortages in health care. In its letter, APTA urges CMS to work with Congress to change language in the 21st Century Cures Act to extend locum tenens to all qualified PTs regardless of geographic location.

    Also on the list
    Alone or in combination, the letters recommend a number of other changes including allowing PTs working in the home health and SNF settings to make "insignificant" changes to plans of care without being required to notify the physician (in the event that CMS doesn't adopt the larger plan-of-care suggestions), standardizing data submission, removal of certain data collection requirements and standardizing others, and prohibiting Medicare Administrative Contractors from requiring a physician order for PTs to furnish wound care.

    APTA regulatory affairs staff is in regular contact with CMS staff and will continue to press for needed changes and share information as it becomes available.

    CMS Coding Reversal Will Apply to Claims Made Beginning January 1, 2020

    Details are still emerging around exactly how CMS intends to walk back a decision to change coding methodologies that prevented PTs from billing an evaluation performed on the same day as therapeutic activities and/or group therapy activities. But we know a little more now: namely, that the decision is retroactive to January 1 of this year, the date when the short-lived system was set in place.

    APTA pressed CMS for the logistics of how its do-over would be worked out as soon as its decision was announced on January 24. On January 28, CMS informed the association that while the agency is still working on its messaging to the Medicare administrative contractors, or MACs, the reversal will be extended to claims made from January 1, 2020, on.

    The current state of flux leaves physical therapy providers with three basic options: delay submitting claims until after CMS gives the green light; resubmit claims denied because of the coding edits once the change is official; or appeal any claims denied due to the edits to the MAC, supplying supporting documentation.

    APTA regulatory affairs staff will remain in communication with CMS on the change and share new information as it becomes available.

    Study: Home Health Physical Therapy Improves Abilities of Individuals With Dementia

    In this review: The Impact of Home Health Physical Therapy on Medicare Beneficiaries With a Primary Diagnosis of Dementia
    (Health Policy and Economics, January 2020)

    The Message
    Physical therapy delivered at home has a role to play in improving the lives of individuals with dementia, according to authors of a study that found any physical therapy increased the probability of improvement in activities of daily living — ADLs — by 15.2%. Although those probabilities improved in relation to the number of visits received, the greatest rate of increase in ADL function seemed to occur in patients who received between six and 13 visits.

    The Study
    Researchers analyzed CMS data drawn from the 2012 Outcome and Assessment Information Set and the Home Health Research Identifiable File, focusing on patients 66 and older who had a primary diagnosis of dementia and received in-home care. A total of 1,477 patients were included in the analysis.

    The study focused on whether patients with dementia improved ADL performance during the course of their care, and whether physical therapy visits could be correlated to increased chances of improvement. ADL items assessed included grooming, upper body dressing, lower body dressing, bathing, toilet transferring, toileting hygiene, transferring to bed or chair, ambulation, feeding and eating, the ability to prepare light meals, and the ability to use a phone.

    APTA members Cherie LeDoux, PT, DPT; Jason Falvey, PT, DPT, PhD; and Jennifer Stevens-Lapsley, PT, MPT, PhD, were among the authors of the study.


    • Patients who received no physical therapy had a 60% probability of ADL improvement; that probability jumped to 75% for patients receiving any physical therapy.
    • The probability of ADL improvement increased with the number of physical therapy visits received, with improvement probability rising to 80.3% for patients receiving six to 13 visits, and to 88.9% for patients who received 14 or more visits.
    • Among all 1,477 patients, 62% received at least one physical therapy visit, with an overall median of four physical therapy visits received.
    • Among the patients who received physical therapy, 52% received between six and 13 visits, 41.3% received one to five visits, and 6.7% received 14 or more visits.
    • Authors believe the most significant improvement rates were associated with the six to 13-visit range, writing that the improvement rates associated with 14 visits and more as statistically insignificant.

    Why It Matters
    The authors write that their study comes when changes to home health payment "may produce downward pressure on home health rehabilitation services … generally discouraging therapy use and potentially increasing avoidable functional decline for [persons with dementia]." Their findings, they assert, help to establish the role of physical therapy in a provider environment that "incentivizes functional improvement."

    "In this study, skilled PT utilization is significantly associated with greater mobility and ADL function in individuals with a primary diagnosis of dementia," the authors write, adding that "our results suggest patients [with dementia] should receive a PT evaluation at minimum as a standard of care."

    Keep in Mind …
    Authors cite limitations in their study, including an inability to correct for possible variation in treatment allocation such as patient participation levels and clinician bias. The study also has a relatively small sample size and did not account for variations in dementia types among patient data analyzed.

    [Editor's note: author Jason Falvey was awarded a 2019 Foundation for Physical Therapy Health Services Research Pipeline Grant. Author Stevens-Lapsley has also received Foundation funding, and author LeDoux is the recipient of a 2019 Foundation Promotion of Doctoral Studies grant.]

    5 Things PTs and PTAs Need to Know About Naloxone

    APTA has long supported the important role of physical therapy in providing a safe alternative to opioids for pain management. But as health care stewards in society, another way PTs and PTAs can contribute is by having the medication naloxone available in case of an overdose.

    In fact, APTA’s official position is that naloxone should be accessible where PT services are provided to be administered to reverse the effects of an opioid overdose in accordance with recommendations from the Surgeon General of the United States. A year ago, in an address to APTA leaders, the Surgeon General urged association members to learn to administer the drug.

    Here are 5 things you should know about naloxone, along with links to more information—including the Surgeon General’s recommendations.

    1. Before administering naloxone, make sure to check your State Practice Act.
    Refer to state practice acts for specifics on regulations that might be in place for the administration of naloxone. Also check insurance policies for the hospital or clinic to make sure any possible liabilities are covered.

    2. Naloxone can rapidly reverse an opioid overdose.
    Naloxone is an opioid antagonist, which means it attaches to opioid receptors and reverses and blocks the effects of other opioids. Naloxone can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose. Naloxone is not a treatment for opioid use disorder—it has no effect on someone who does not have opioids in their system.

    3. Learn about naloxone.
    Naloxone normally would fall within a drug category that requires a prescription, but in response to the opioid epidemic all 50 states have passed laws to make it easier to obtain, and most pharmacies carry it. Either the pharmacist can prescribe it on the spot when you go to a pharmacy, or a standing order can be set up that acts like a prescription anyone can fill. Find out which states make naloxone available without a prescription, or search the internet for “get naloxone in [your city].” And check out these Q&As on acquiring naloxone.

    To learn even more, view the US Substance Abuse and Mental Health Services Administration (SAMHSA) toolkit that outlines steps for first responders: Toolkit: 5 Essential Steps for First Responders.

    4. Consider training for administering naloxone — it’s easy to find.
    Most local health departments provide training and information, as does the American Red Cross.

    5. Include an emergency response plan for your hospital or clinic.
    Make sure administration of naloxone in case of opioid overdose is included in plans for medical emergencies in your facility. Refer to the SAMHSA toolkit for guidance.

    Get more information from the Surgeon General, CDC, HHS, FDA, and other sources.

    Payment Win: CMS Reverses Most of Its Damaging Coding Edits, More Details to Come

    The issue: On January 1, CMS changed some of its correct coding methodologies in ways that prevented PTs from billing an evaluation and therapeutic activity and/or group therapy services delivered on the same day, a common practice in physical therapy.

    The news: APTA and its members engaged in extensive advocacy efforts to convince CMS to rethink its decision. On January 24, CMS announced that it would do away with the most problematic changes and, for the most part, return to the coding rules PTs used in 2019.

    What it means: PTs will be able to return to billing for therapeutic activities (97530) delivered on the same day to the same patient as PT or occupational therapy evaluations billed under codes (97161, 97162, 97163, 97165, 97166, 97167). PTs (and occupational therapists) will also be allowed to return to billing the group therapy code (97150) with those evaluation codes.

    Keep in mind: There are still lots of details to be worked out, including the timeline for CMS to notify Medicare Administrative Contractors of the change, and whether it's retroactive. Additionally, a few of the January 1 restrictions remain, primarily related requirements around use of the 59 modifier/X modifier.

    The pressure paid off
    After a concerted effort by APTA, its members, and other stakeholders, CMS relented on the most detrimental parts of its changes to the edits that prohibited payment for certain activity codes if they're used on the same day as evaluation codes. The win means that PTs will be able to, for the most part, return to coding practices that were in effect prior to January 1, 2020. CMS has not yet shared details on effective date and the process for implementation of the changes.

    CMS has not yet shared details on effective date and the process for implementation of the changes.

    In a January 24 letter to APTA and other associations, Cathy Cook, MD, medical director of CMS coding contractor Capitol Bridge, wrote that "after reviewing this issue more closely, CMS has made the decision to retain the edits that were in effect prior to January 1, 2020."

    The return to the pre-January 1 coding environment reverses a CMS National Correct Coding Initiative edit that prevented PTs and OTs from billing for therapeutic activities (97530) if any of the PT or OT evaluation codes were billed the same day for the same patient. That prohibition crossed disciplines that use the same provider number, which prevented, for instance, an OT for billing for therapeutic activities with a particular patient on the same day a PT in the same practice billed for evaluation of the patient. In addition, CMS applied restrictions on billing for group therapy on the same day as PT or OT evaluations.

    With the letter from Capitol Bridge, those restrictions were undone.

    "The coding edit CMS imposed on January 1 not only ran counter to best practice in physical and occupational therapy, but was not consistent with CMS' own stated goals for care," said Kara Gainer, APTA's director of government affairs. "APTA and its members conveyed that message in large numbers, and in no uncertain terms. We're extremely pleased that CMS listened to the case we made and did the right thing for patients."

    While the reversal eliminated the most problematic parts of the January 1 edits, a few restrictions still remain: CMS will continue to require the 59 modifier/X modifier to be applied if a PT wants to receive payment for furnishing both manual therapy (97140) and an evaluation using any of the physical therapy evaluation codes (97161, 97162, 97163) on the same day for the same patient, or if billing for therapeutic activities (97530) or group therapy (97150) delivered on the same day as a physical therapy reevaluation (97164).

    The letter from Capitol Bridge also states that CMS will provide further information when it becomes available regarding impacted claims. Other details, such as how and when Medicare Administrative Contractors will be notified of the change, are unclear as of publication of this article. APTA will provide details as they become available.

    Katy Neas, APTA's executive vice president of public affairs, says that even with the remaining restrictions, the reversal from CMS is a significant one.

    "It's never easy to undo something that's been imposed by CMS and is already up and running," Neas said. "The fact that CMS changed course so quickly on so many of the most damaging parts of the coding edits is a testament to what can happen when APTA, its members, and stakeholders speak with a unified voice."

    Questions about where things stand in the wake of the CMS change? Contact advocacy@apta.org.

    What's Happening at the State Level: Hot Issues for 2020

    It's that time: Across the country, most state legislatures are either back in session or headed that way. And again this year, issues important to PTs, PTAs, and the patients they serve are on the radar in many statehouses.

    In preparation for what promises to be another busy year, we've put together a list of some of the issues that will get attention from lawmakers in the coming weeks and months. Take a look at what's coming — and then don't forget to help press for needed change by contacting your APTA chapter and the national office to sign up for action alerts, and see how you can get involved. (And check out APTA's State Advocacy webpage.)

    Direct Access
    States with potential legislation in 2020: Alabama, Kansas, Minnesota, Mississippi, Missouri, New York,  South Carolina, Tennessee

    Background: Improving direct access to physical therapy, ideally without a physician referral, is a longstanding priority for the association and its chapters. And we've made progress: All states now have some form of direct access, but some forms are more limited than others, imposing restraints such as referral requirements and visit limits for specific interventions. Legislative energy is now being devoted to improving these more restrictive systems, bolstered by a recent APTA consponsored study that found unrestricted direct access to physical therapy for low back pain saves money and lowers utilization of services overall.

    Resources: Direct Access at the State Level webpage

    States with potential legislation in 2020: Arizona, Georgia, Rhode Island

    Background: Telehealth provisions for PTs are explicitly included in laws and/or regulations in 16 states, with nine states allowing Medicaid reimbursement for telerehab and 11 more including language that opens up that possibility. The U.S. Department of Veterans Affairs allows PTs to engage in telehealth, to successful results. The states listed above want to add telehealth the PT scope of practice, allow for Medicaid reimbursement for telehealth delivered by PTs, or both.

    Resources: Telehealth webpage

    Physical Therapy Compact
    States with potential legislation in 2020: District of Columbia, Massachusetts, Michigan, Ohio, Pennsylvania, Rhode Island, South Dakota, Vermont, Wisconsin

    Background: The system that allows PTs and PTAs licensed in one compact state to obtain practice privileges in other compact states grew to include 26 states in 2019, with five more — Arkansas, Delaware, Georgia, Maryland, and Virginia — having adopted the legislation in advance of enactment. Widespread participation in the compact is a professional game-changer, particularly as PTs' and PTAs’ ability to participate in telehealth grows.

    Resources: Physical Therapy Licensure Compact webpage

    Dry Needling
    States with potential legislation in 2020: California, Connecticut (pending a court ruling), Hawaii, New Jersey (held over from 2019)

    Background: Currently, 35 states and the District of Columbia allow PTs to perform dry needling, seven states prohibit it, and eight states are silent on the issue. Chapters from the states listed above are looking to add a specific mention of dry needling to their PT practice acts.

    Resources: Dry Needling in Physical Therapy webpage

    Fair Copays
    States with potential legislation in 2020: Georgia, New York, Ohio, Rhode Island, Virginia

    Background: Like direct access, the issue of fair copays has been a central advocacy focus for some time at both the state and federal levels. Many insurance provisions classify PTs as specialists and impose higher copays; it's an approach that ignores the fact that physical therapy often requires multiple visits, making seeing a PT cost prohibitive. APTA and its chapters want to change that by, at the very least, following a lead established in Kentucky in 2011 that limits physical therapy copays to no more than the copay for a visit to a primary care provider.

    Resources: Fair Physical Therapy Copays webpage

    States with potential legislation in 2020: Connecticut, Illinois, Rhode Island

    Background: The importance of PTs to achieve practice authority for ordering and performing appropriate imaging studies was underscored by the APTA House of Delegates in 2016, when it directed the association to press for changes to imaging restrictions. Currently, only Colorado, Wisconsin, and Utah expressly allow PTs to order imaging under certain conditions.

    Resources: Imaging webpage

    Utilization Management
    States with potential legislation in 2020: Oregon

    Background: Used properly, utilization management can help PTs provide patient-centered and timely care to patients; too often, however, it serves as little more than a barrier to needed care and an excessive administrative burden for providers. States are looking for ways to better regulate the practice so that it doesn't get in the way of patient access to needed services.

    Resources: APTA Utilization Management Toolkit

    Practice Act Updates
    States with potential legislation in 2020: Alaska, Florida, Tennessee

    Background: Times change, and so do concepts of legal scopes of practice for PTs and scopes of work for PTAs. A large-scale revision of a state's PT and PTA regulatory language can be a major undertaking, but chapters regularly step forward to take on the challenge and ensure that PTs in their states are practicing under laws that aren't antiques.

    Resources: Jurisdictional Scope of PT Practice webpage

    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.

    APTA's Physical Therapy Outcomes Registry Again Receives QCDR Designation for MIPS Reporting, Adds New Measures

    APTA's Physical Therapy Outcomes Registry has been approved for the fourth year in a row by the U.S. Centers for Medicare and Medicaid Services as a qualified clinical data registry, or QCDR. This designation means that participating physical therapists can submit Merit-based Incentive Payment System — MIPS — reporting data to CMS directly from the registry. QCDR approval recognizes APTA's demonstrated expertise in quality measure development.

    The Physical Therapy Outcomes Registry supports 19 Quality Payment Program measures, 11 QCDR measures, and two electronic clinical quality measures. CMS requires that the electronic clinical quality measures must be reported using certified electronic health record technology, also known as CEHRT.

    As of January 2019, PTs who provide services under Medicare Part B who meet qualifying criteria must participate in either MIPS or an Advanced Alternative Payment Model (Advanced APM). PTs who participate in the Registry can meet MIPS requirements in both the Quality and Improvement Activities categories. Submitting data via a QCDR also earns "bonus" points in the Promoting Interoperability category, which is not yet required for PTs.

    Whether or not PTs participate in MIPS, according to Heather Smith, PT, MPH, APTA's director of quality, APTA’s registry is a valuable tool for optimizing patient outcomes.

    "Participants have found that registry data has opened their eyes to areas for improvement, and even informed changes to the way they deliver care," Smith said. "Registry analytics allow therapists to objectively understand how their practice patterns and interventions are impacting patient outcomes."

    Registry users can access nonproprietary outcomes measures supported by CMS, as well as specific measures shared from other QCDRs.

    By directly integrating with EHRs, the registry enables PTs — whether or not they participate in MIPS — to leverage their existing EHR data to track and benchmark outcomes, apply dashboard insights to improve quality of care, and demonstrate the value of physical therapist services to payers and providers. For more information about the Physical Therapy Outcomes Registry, visit www.ptoutcomes.com.

    Headed to the APTA Combined Sections Meeting in February? Visit the APTA Pavilion in the Exhibit Hall to learn more about how the registry can benefit your practice. Related education sessions include "Demonstrating Value: Using Clinical Data and Databases to Improve Outcomes for Patients and the Population" and "Through the Looking Glass: What Are the Emerging Payment and Quality Issues?"

    2020 Federal Advocacy Forum Coming March 29; Registration Open Through March 16

    While 2019 saw some real advocacy achievements for the physical therapy profession, the year also brought challenges to tackle in 2020 — not the least of which is the proposal by Medicare to cut reimbursement to physical therapy in 2021. And with APTA's fight against the cut already in motion, the 2020 Federal Advocacy Forum, set for March 29-31, couldn't come at a better time.

    Registration is now open for the annual event, which brings PTs, PTAs, and students together in Washington, DC, for a three-day conference that provides the latest on regulatory and legislative issues affecting the profession, and ends with an opportunity for attendees to apply what they've learned by making in-person visits to Senate and House offices. Registration deadline is March 16.

    The forum's keynote speaker will be Paul Begala, political analyst and commentator at CNN. An affiliated professor of public policy at Georgetown University, Begala served as counselor to President Bill Clinton.

    Begala's participation is in keeping with the forum's tradition of offering a variety of speakers with diverse perspectives. Past keynote speakers include political commentator Fred Barnes, FOX News host Tucker Carlson, and political strategist Donna Brazile.

    Other forum activities will include an evening reception and breakout sessions on advocacy-related topics.

    "The proposed 8% cut will be one of the issues the profession will share with their elected officials, and APTA will continue to educate Congress about the essential role that physical therapists play in the delivery of quality health care for patients of all ages across the country," said Michael Matlack, APTA's director of congressional affairs. "Now, more than ever, the voice of the physical therapy profession is critical to the health and well-being of our patients and our industry. "

    Want to get a feel for what the Federal Advocacy Forum is all about? Check out the video recap of the 2019 forum on the Federal Advocacy Forum webpage.

    NCCI Code Edits: Your Questions Answered

    Background: A surprise coding change issued by the Centers for Medicare and Medicaid Services (CMS) caused an uproar in the physical therapy community earlier in January, and for good reason: The new requirements state that CMS won't reimburse for certain activity and evaluation codes if they're used in the same day. APTA argues that accepted physical therapist practice often includes the startup of care on the same day as evaluation (and continued care on the same day as reevaluation), and that the prohibition runs counter to CMS' own aims for care.

    Reaction: Since the announcement, Capitol Bridge, LLC, CMS' National Correct Coding Initiative (NCCI) contractor, has been inundated with comments from PTs, PTAs, and other stakeholders slamming the decision and requesting that the change be reversed. And it's not too late to add your voice to the effort. APTA is communicating with representatives from Capitol Bridge, CMS, and the American Medical Association, which plays a significant role in coding development.

    Where things stand: As of the date of this report, no changes have been made. That leaves PTs and PTAs to deal with the current prohibition, as problematic as it may be.

    To help you navigate the system as it is, here are answers to some of the most common questions we've been receiving on the NCCI coding change.

    1. What are NCCI Procedure-to-Procedure (PTP) code pair edits?
    NCCI PTP edits are intended to prevent payment of services that should not be reported together. Each edit has a Column One and Column Two Health Care Common Procedure/Current Procedural Terminology (HCPCS/CPT) code, called a “pair.” If a provider reports the two codes of a pair for the same beneficiary on the same date of service, only the Column One code is eligible for payment; the Column Two code is denied unless a clinically appropriate NCCI-associated modifier is also reported.

    As for modifiers, each PTP edit has a modifier indicator, represented by (0), (1), and (9), that appears after the code number. Here's what those numbers mean:

    • 0 - There are no circumstances in which a modifier would be appropriate. The services represented by the code combination will not be paid separately.
    • 1 - A modifier is allowed in order to differentiate between the services provided. Assuming the modifier is used correctly and appropriately, this distinction provides the basis upon which separate payment for the services billed may be considered justifiable.
    • 9 – The deletion date of the code pair is the same as the effective date. In other words, these edits are no longer active, so the code combinations are billable, and no other modifier is needed.

    2. What happens if I bill 97530 (therapeutic activities) and 97161, 97162, or 97163 (physical therapy evaluations) together on same day for same patient?
    This is at the heart of the recent edit. Under the new rules, the use of both codes is prohibited, and there's no modifier that you can use to bypass the denial. That includes the 59 modifier/X modifier: You can't use the 59 modifier/X modifier when billing 97530 with 97161, 97162, or 97163 to bypass the edit.

    Bottom line: when 97530 and one of the physical therapy evaluation codes are billed together on the same day for the same patient, the evaluation code will be denied. This is because in the PTP edits list, 97530 is the Column One code and 97161, 97162, and 97163 are Column Two codes (see the answer to question 1 for more background on Column One and Column Two codes).

    3. Why is 97530 (therapeutic activities) in Column One and 97161-97163 (physical therapy evaluations) in Column 2?
    Good question. We believe this PTP edit is inconsistent with the general guidelines for PTP edits, and it's one of the reasons APTA and other stakeholders are working with CMS to have this edit removed as soon as possible.

    4. What happens if I bill 97150 (group therapy) and 97161, 97162, or 97163 (physical therapy evaluations) together on the same day for same patient?
    As with the therapeutic activities code covered in question 2, the answer is, you won't get reimbursed for the evaluation — and there is no modifier you can use to bypass the edit, including the 59 modifier/X modifier. This is because in the PTP edits list, 97150 is the Column One code and 97161, 97162, and 97163 are Column Two codes. Under the policy, when Column One and Column Two codes are billed, the Column One code is eligible for payment and the Column Two code is denied.

    5. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97140 (manual therapy) and 97161-97163 (physical therapy evaluation codes)?
    Yes. It's possible to bypass the edit by using the 59 modifier/X modifier when billing 97140 with the physical therapy evaluation codes (97161, 97162, or 97163). If you don't use the modifier for this combination of codes, CMS will deny the manual therapy code. This is because in the PTP edits list, 97161-97163 is the Column One code and 97140 is the Column Two code. Under the policy, when Column One and Column Two codes are billed, the Column One code is eligible for payment and the Column Two code is denied — unless an appropriate modifier is used.

    6. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97530 (therapeutic activities) and 97164 (physical therapy re-evaluation)?
    Yes, you are permitted to bill 97530 with 97164 if you use the 59 modifier/X modifier. If you do not bill with the appropriate modifier, then 97164 (Column Two code) will be denied. (See question 5).

    7. Can I use the 59 modifier/X modifier to bypass the PTP edit for 97150 (group therapy) and 97164 (physical therapy re-evaluation)?
    Yes, for the same reason explained in questions 5 and 6.

    8. Do PTP edits apply across disciplines?
    Unfortunately yes, when services are billed under the same provider number. For example, if the occupational therapist performs 97530 on the same day as the PT who bills an evaluation code, the evaluation code will be denied if the services of both providers are billed under the same provider number (as in institutional billing).

    9. What settings do PTP code pair edits apply to?
    The NCCI edits consist of two provider-type choices of PTP code pair edits: practitioners and hospitals.

    By "practitioners," CMS means that the NCCI edits apply to claims submitted by physicians, nonphysician practitioners, and ambulatory surgical centers. This includes PT private practitioners.

    The definition of "hospital," for purposes of this edit, extends to outpatient hospital services and other facility services including, but not limited to, therapy providers in Part B skilled nursing facilities, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech-language pathology providers, and home health agencies for certain claims billed under Type of Bill (TOB) 22X, 23X, 75X, 74X, 34X.

    10. Do NCCI edits apply to all third-party payers?
    Yes and no. Technically, the NCCI edits only apply to Medicare fee-for-service, but the majority of commercial payers do use the NCCI edits in their systems, so there's a good chance you'll need to comply with the edits even if you aren't working with Medicare. Some workers compensation programs and self-insured plans may create their own edits.

    11. Are there other edits I should be aware of?
    Yes, there are many PTP edits for hospital and practitioner settings. The PTP edits are updated on a quarterly basis. To stay up to date, visit the CMS PTP Coding Edits page, scroll down to related links, and click on the appropriate setting link (Hospital PTP edit or Practitioner PTP edit) for the relevant time period.

    12. What happens next?
    APTA continues to pressure CMS to remove these edits. CMS has met with the NCCI contractor to discuss the edits and is working on a resolution. We hope to have additional information to share in the near future.

    Looking for additional information about NCCI edits? Visit the National Correct Coding Initiative Edits webpage or contact APTA at advocacy@apta.org.

    The Good Stuff: Members and the Profession in the Media, January 2020

    "The Good Stuff" is an occasional series that highlights recent media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs, PTAs, and students are transforming health care and society every day. Enjoy!

    PT leadership for USA Gymnastics: Kim Kranz, PT, DscPT, has been named USA Gymnastics' first vice president of Athlete Health and Wellness. (Around the Rings)

    When resolutions become a pain: Ryan Balmes, PT, DPT, and Jessica Douglas, PT, MSPT, offer advice on how to take on that New Year's fitness resolution without getting hurt. (Boston Globe)

    Redskins score a key PT: Kevin Wilk, PT, DPT, FAPTA, is now the Washington Redskins' medical trainer. (Redskins Wire)

    The importance of the pelvic floor: Riana Taktikos, PT, DPT, explains the ways pelvic floor physical therapy can help conditions that many people think they just have to live with. (Warren, Ohio, Tribune-Chronicle)

    Home is where the gym is: David Reavy, PT, MBA, shares his favorite piece of home gym equipment. (Gear Patrol)

    Solving middle back pain: Tony D'Angelo, PT, outlines what's different about middle back pain, and provides tips on addressing it. (Shape)

    Balance in all things: Ben Fung, PT, DPT, MBA; and Kathleen Walworth, PT, DPT, stress the importance of good balance, and suggest ways to improve. (Vitacost.com)

    Flying with the Eagles: St. Francis University (Pennsylvania) physical therapy students helped members of the Philadelphia Eagles create adaptive ride-ons for kids with disabilities at a recent GoBabyGo event. (Altoona, Pennsylvania Mirror)

    The power of neurologic physical therapy: Ian Lonich, PT, DPT, is making a difference for patients in southwest Pennsylvania. (Uniontown, Pennsylvania Herald-Standard)

    Pillow talk: Karena Wu, PT, DPT, MS, discusses the advantages of body pillows. (Bustle)

    Goodbye, crunches: Bethanie Bayha, PT, DPT, provides insight on better core-strengthening exercises. (Self)

    Go ask pectoralis: Danielle Weis, PT, DPT, discusses ways to counter pectoralis muscle imbalances that cause neck pain. (Well and Good)

    The PT's role in responding to autism spectrum disorder: Anjana Bhat, PT, is leading the way helping children with ASD improve social skills and communication through physical therapy. (University of Delaware News)

    Speedbumps on the road to fitness: Todd Kruse, PT, MPT, shares insights on preventing injury while pursuing fitness resolutions. (KEYC12 News, Mankato, Minnesota)

    I'll be sore for Christmas: Anna Friedman, PT, says yes, Virginia, there is a "Santa strain." (KOMO News, Seattle)

    Delivering postpartum fitness: Carrie Pagliano, PT, DPT, unpacks the trend toward exercise programs for new mothers. (Wall Street Journal)

    GoBabyGo, Colorado style: Jessica Albers, PT; and Kristen Holman, PT, DPT, spearheaded a recent effort to retrofit children's vehicles to provide independence — and a lot of fun — for children with disabilities. (Coloradoan)

    There's no place like foam: Theresa Marko, PT, DPT, MS, discusses the advantages and uses of foam rollers. (Insider)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    We Have a Winner: ONE by ONE Member Recruitment Effort's Prizewinner List Continues to Grow

    Heather Prather, PT, DPT, says APTA membership gives her the information and peer connections she needs to thrive in her profession. And she must make a pretty compelling case, at least as far as new APTA member Erin Brannan, PTA, is concerned.

    Prather is the latest prize-drawing winner in APTA's ONE by ONE membership campaign, a project that encourages members to recruit their fellow PTs, PTAs, and physical therapy students — in Prather's case, it was Erin Bannan — to join APTA. Every member who refers a new or returning member is entered into a monthly drawing for a free year of APTA membership. In December, Prather's name was drawn. Both Prather and Brannon are from New Mexico.

    "I renewed my APTA membership, as I enjoy having access to the clinical tool box for quick access to different outcome measures and appropriate exercises and protocols to utilize based on diagnosis," Prather said. “I enjoy receiving the PT in Motion magazine and reading about up-to-date topics and what’s happening in the physical therapy world. The community boards are helpful to see what is being discussed, or as a lifeline to ask fellow members their advice or suggestions from their experiences on certain topics. It is great to be a member of APTA, to show support and that we are proud of our profession."

    The ONE by ONE campaign also holds a monthly prize drawing for new or renewing members referred through the campaign, awarding winners a subscription to APTA's Passport to Learning continuing education access system. The most recent winner was Steve Baron, PT, DPT, a new member from Pennsylvania. Baron was recruited by Matthew Will, PT, DPT, also from Pennsylvania.

    ONE by ONE offers additional opportunities to win, including a prize for the participating section that experiences the largest year-over-year growth rate during the campaign, and the chance to win one of five iPads that will be given away in a drawing of members who recruit five or more new members by the end of the campaign.

    Details on the recruitment effort — and a list of past prize winners — can be found on the ONE by ONE webpage, including a toolkit that gives you everything you need to join the campaign. ONE by ONE runs through September 30, 2020.

    APTA CEO Moore Joins Amputee Coalition Board

    APTA Chief Executive Officer Justin Moore, PT, DPT, has been unanimously elected to serve a four-year term on the Board of the Amputee Coalition, a leading national advocacy organization.

    The Amputee Coalition serves the more than two million Americans with limb loss and limb difference and more than 28 million at risk for amputation. Its mission is to raise awareness for and advocate on behalf of that population on Capitol Hill, and ensure that legislators and policymakers are educated about the unique needs of this community. The coalition’s work helps to secure the services, supports, and resources for individuals to live the lives they want to live.

    Moore will join 11 other board members who advise the organization on initiatives including federal policy outreach, insurance protections for patients, the organization’s National Limb Loss Resource Center, summer youth camp, and hospital partnerships.

    “Having Justin join our esteemed board of directors strengthens our ability to make progress toward our strategic goals and grow the coalition,” said Coalition CEO Mary Richards. “We all look forward to his vision, leadership, and insights about the federal policy landscape and how we can best serve our community.”

    “I am honored to have been elected to the Board of Directors of the Amputee Coalition," Moore said. “Clearly the coalition’s mission closely reflects APTA’s own vision — transforming society by optimizing movement to improve the human experience — which makes this position all the more significant to us. I look forward to working with the coalition to advocate for those they serve.”

    Paul Rockar Named Foundation President

    The Foundation for Physical Therapy Research (FPTR) has named former APTA President Paul Rockar Jr., PT, DPT, MS, as its president. Rockar, who served as a foundation trustee for three years prior, assumed his new role on January 1, 2020.

    Rockar is a well-known figure in the physical therapy profession, having served as a member of the APTA Board of Directors, as its vice president, and finally, as president of the organization from 2012 to 2015. Rockar is the former CEO of the Centers for Rehab Services.

    APTA and the foundation have a more than 40-year relationship focused on promoting physical therapy research. As a designated Pinnacle Partner of the foundation, APTA invested over $500,000 to support foundation initiatives including scholarships and fellowships in 2019.

    In his role as president, Rockar will work alongside his fellow Board of Trustees members to continue the foundation’s 2019-2022 strategic plan.

    “I am honored to have been chosen by my fellow trustees to lead FPTR at a time when research is so important to the profession,” said Rockar. “I look forward to collaborating with our partners and like-minded supporters — including APTA — to support research that leads to the best clinical guidelines and excellent patient care.”

    Rockar succeeds Edelle Field-Fote, PT, PhD, FAPTA, who concluded her term at the end of 2019.

    Separate Studies, Similar Conclusions: Bundling for Knee, Hip Replacement Seems to be Working

    Has all the bundling been worth it? Two new studies of bundled care models used by the Centers for Medicare and Medicaid Services (CMS) conclude that, at least for lower extremity joint replacement (LEJR), the answer is yes. Taken as a whole, the studies make the case that while the savings achieved through some bundled care models may not be dramatic, they do exist — and aren't associated with a drop in quality.

    The studies, published in Health Affairs, take different approaches to answering questions about the effectiveness of bundling programs mostly associated with CMS' voluntary Bundled Payments for Care Improvement (BPCI) initiative: one was a systematic review that analyzed existing research (abstract only available for free) on the programs, while the other focused on data from hospitals that did and did not participate in BCPI (abstract only available for free) over a three-year period. Their conclusions, however, had much in common.

    The bottom line, according to both studies, is that bundled care models for LEJR seem to be lowering overall costs without sacrificing quality.

    The systematic review revealed that most studies that evaluated spending recorded decreases in overall postacute care spending of between $591 and $1,960, while the hospital data researchers identified an average 1.6% decrease in episode spending for LEJR — about $377 per patient. At the same time, neither study uncovered evidence of reduced quality outcomes, with the hospital study finding variances between BPCI and non-BPCI care for LEJR of less than 2%. The systematic review found that, if anything, research indicates that bundled care tends to lead to lower rates of hospital readmission, a datapoint strongly associated with quality.

    The studies did have some differences. The hospital data researchers focused solely on LEJR data, which they describe as the most common procedure associated with BPCI, while the systematic review included a bundled care model for a range of procedures. In the end, authors of the systematic review found that bundled payment "has yet to demonstrate [benefits similar to those associated with LEJR bundling] for other clinical episodes," including spinal fusion, shoulder arthroplasty, and cardiac surgery. Another difference between the studies: The systematic review included data from CMS' Comprehensive Care Joint Replacement (CJR) model mandated for use in some 450 facilities across the country; the hospital data review excluded CJR facilities.

    [Editor's note: APTA offers multiple resources on bundling, including separate webpages devoted to BPCI Advanced participation and the CJR.]

    Each study offered its own takeaways. The systematic review emphasized the effectiveness of bundling for LEJR and suggested that CMS "scale up” its bundling programs in those areas, while cautioning that more work needs to be done on bundling programs for other procedures, especially those that tend to be associated with higher baseline patient complexity. The hospital data study, focused on LEJR only, found that most of the savings associated with bundling came from early adopters (which maintained their savings over time), and less so from facilities that joined later, which "may have been less able to influence episode spending." That study also acknowledged that while voluntary bundling models may be subject to cherry-picking of less complex patients, data revealed that "it does not fully account for associated savings."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    New APTA-Supported CPG Looks at Best Ways to Improve Walking Speed, Distance for Individuals After Stroke, Brain Injury, and Incomplete SCI

    In this review: Clinical Practice Guideline to Improve Locomotor Function Following Chronic Stroke, Incomplete Spinal Cord Injury, and Brain Injury
    (Journal of Neurologic Physical Therapy, January, 2020)

    The message
    A new clinical practice guideline (CPG) supported by APTA and developed by the APTA Academy of Neurologic Physical Therapy concludes that when it comes to working with individuals who experienced an acute-onset central nervous system (CNS) injury 6 months ago or more, aerobic walking training and virtual reality (VR) treadmill training are the interventions most strongly tied to improvements in walking distance and speed. Other interventions such as strength training, circuit training, and cycling training also may be considered, authors write, but providers should avoid robotic-assisted walking training, body-weight supported treadmill training, and sitting/standing balance that doesn't employ augmented visual inputs.

    The study
    The final recommendations in the CPG are the result of an extensive process that began with a scan of nearly 4,000 research abstracts and subsequent full-text review of 234 articles, further narrowed to 111 randomized controlled trials (RCTs), all focused on interventions related to CNS injuries, with outcome data that included measures of walking distance and speed. CPG panelists evaluated the data and developed recommendations, which were informed by data on patient preferences and submitted for expert and stakeholder review.

    Development of the CPG was supported through an APTA-sponsored program that assists APTA sections — in the case, the Academy of Neurologic Physical Therapy — in the development stages such as drafting, appraisal, planning, and external review (for more detail on the program, visit APTA's CPG Development webpage).


    • Moderate- to high-intensity (60%-80% of heart rate reserve or up to 85% of heart rate maximum) walking training was associated with the strongest evidence for improvements in walking speed and distance.
    • Walking training using VR also fared well, due in part to the ability of a VR treadmill system to allow "safe practice of challenging walking activities," something that's hard to do in a more traditional hospital or clinic setting.
    • Strength training, while not included among the interventions that should be performed, was designated as an intervention that may be considered. Authors cite inconsistent evidence on the connection between strength training and improved walking speed and distance, but they acknowledge potential benefits.
    • Also among the list of interventions that "may be considered": circuit training, as well as cycling training. In both cases, authors cite a paucity of evidence related to how the interventions affect walking speed and distance. They note that these interventions may be revisited during a future reevaluation of the CPG.
    • Body-weight supported treadmill training was labeled as an intervention that should not be performed in order to increase walking speed and distance, with authors finding little evidence supporting the approach, which is often associated with a greater cost. However, they write, the individuals included in the studies reviewed for the CPT were able to ambulate over ground without the use of a body-weight support device, and "different results may occur in those who are nonambulatory or unable to ambulate without the use of [body-weight support]."
    • Both static and dynamic (nonwalking) balance training and robotic-assisted walking training were also characterized as interventions that should not be performed. Authors acknowledge the ways that postural stability and balance are associated with fall risk and reduced participation, but they were unable to find sufficient evidence to support these particular interventions as effective in increasing walking speed and distance (although static and dynamic balance training with VR fared a bit better). As for robotic-assisted walking training, CPG authors note that while ineffective for individuals with CNS who were already ambulatory, "this recommendation … may not apply to nonambulatory individuals or those who require robotic assistance to ambulate."

    Why it matters
    Authors note that "the implementation of evidence-based interventions in the field of rehabilitation has been a challenge," and they believe that the new CPG offers a real opportunity for clinicians to "integrate available research into their practice patterns." Further, they believe that the CPG has arrived at an important moment in the evolution of health care, with its greater emphasis on evidence for the cost-effectiveness and outcomes of various interventions.

    More from the study
    The CPG also offers tips for clinicians to implement its recommendations, including acquiring equipment to help providers monitor vital signs, implementing "automatic prompts in electronic medical records that will facilitate obtaining orders to attempt higher-intensity training strategies," providing training sessions for clinicians, establishing organizational policies to promote use and documentation of the recommended interventions, and simply keeping a few copies of the study on hand for easy reference.

    Keep in mind …
    Authors acknowledged that the CPG has a few limitations. While the review of RCTs only is a strength, they write, some of those studies involved small sample sizes, and many lacked details on intervention dosage. Additionally, the CPG does not fully address the potential costs associated with its recommendations — specifically VR — which could impact a clinic's ability to implement a particular intervention. Authors also acknowledge that walking speed and distance are not the only important outcomes related to mobility among individuals with CNS injury, and that other factors such as dynamic stability while walking, peak walking capacity, and community mobility may be incorporated in an assessment of walking function.

    Time to Act: Surprise Coding Complication Ignores Realities of PT Practice and Must be Changed


    NOTE: While comments to this story are welcome, if you want to add your voice to the advocacy effort, please follow the "what you can do" instructions in the last paragraph to contact the NCCI contractor directly. Thanks!


     The US Centers for Medicare and Medicaid Services (CMS) unveiled an unwelcome New Year's Day surprise for outpatient therapy providers, including private practitioners and facility-based settings, when it announced it will no longer allow two frequently used therapy billing codes to be used in combination with evaluation codes. It's a decision that flies in the face of standard PT practice and effective patient care—and CMS and the National Correct Coding Initiative (NCCI) contractor need to hear that perspective loud and clear, from as many stakeholders as possible as soon as possible.

    At issue are current procedural terminology (CPT) codes 97530 (therapeutic activities) and 97150 (therapeutic procedures, group, 2 or more individuals) which, until January 1, were allowed to be billed on the same day as physical therapy or occupational therapy evaluation. Under new CMS NCCI edits, however, that's no longer allowed. And in a further complication, the latest NCCI edits also require use of the 59 modifier—the modifier that's used to indicate that a code represents a service that is separate and distinct from another service to which it is paired—whenever code 97140 (manual therapy) is billed with an evaluation.

    [Editors' note: to view the full list of edits that went into effect January 1, visit the CMS PTP coding edits webpage, and scroll down to the "related links" area, where you can select your setting to find out what's changed.]

    The problem, according to APTA Director of Regulatory Affairs Kara Gainer, is that the changes ignore accepted PT practice, which often includes the startup of care on the same day as evaluation, as well as continuation of care on the same day as revaluation.

    "The whole NCCI process is supposed to put a check on payment for codes that represent overlapping services," Gainer said. "These edits not only miss that mark, they actually have the effect of restricting patient access to the most effective, efficient care, and risking a patient's ability to achieve the best possible outcomes."

    APTA usually receives notice of intended NCCI edits well in advance. That didn't happen in this case, making it imperative that the association, its members, and other stakeholders take action quickly to convince NCCI to reverse its decision. APTA is in communication with Capitol Bridge, LLC, CMS' NCCI contractor, as well as with the American Medical Association, to press for a resolution to the problem.

    What you can do: APTA has developed a comment letter template that you can fill in with your personal information and email to Capitol Bridge, LLC, at NCCIPTPMUE@cms.hhs.gov. Make your voice heard.