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  • Proposed Medicare Fee Schedule Maintains—and Sometimes Increases—Payment for Codes Related to Physical Therapy

    No cuts. And even a few increases.

    That's the major takeaway from the proposed Medicare 2018 physician fee schedule released by the US Centers for Medicare and Medicaid Services (CMS). It's a plan that settles questions about potentially "misvalued" current procedural terminology (CPT) codes by generally accepting work relative value units (RVUs) that had been proposed by an American Medical Association (AMA) advisory committee that worked closely with APTA.

    Under the proposed fee schedule, 13 of 19 CPT codes frequently used by physical therapists (PTs) will retain their 2017 RVUs, with the remaining 6 seeing slight increases. Additionally, RVUs for 2 codes associated with the management and training of patients with orthotics or prosthetics were increased, and a new code was added (977X1, intended for use on a "subsequent encounter" or different date of service from the initial encounter).

    The codes slated for increases are:

    • 97112: Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception, from .45 to .50
    • 97113: Aquatic therapy with therapeutic exercise, from .44 to .48
    • 97116: Gait training, from .40 to .45
    • 97533: Sensory integrative techniques, from .44 to .48
    • 97537: Community/work reintegration, from .45 to .48
    • 97542: Wheelchair management, from .45 to .48

    CMS also proposes leaving practice expense inputs untouched for the 19 major codes and the CPT codes related to orthotics and prosthetics.

    The proposed rule is a significant win for PTs, whose most-often used CPT codes were under scrutiny by CMS as being potentially "misvalued"—a term that usually means CMS thinks it's paying out too much. APTA made the multiyear code analysis process a top priority and worked closely with AMA's Health Care Professional Advisory Committee to develop recommendations to CMS. Those efforts included an extensive survey of PTs administered last fall.

    "The proposed physician fee schedule is an affirmation of the value of physical therapy," said Carmen Elliott, MD, APTA's vice president of payment and practice management. "We are especially grateful for the level of participation we received from APTA members in thoughtfully filling out surveys in 2016. The data AMA received were key in the development of strong recommendations with solid backing in practice."

    Other highlights of the proposed 2018 fee schedule:

    • CMS will debut "patient relationship modifiers," a set of codes intended to describe the role of the provider to the patient, such as "continuous," "episodic," "broad" and "focused." PTs will not be required to report these data in 2018 but could be required to by 2019.
    • The Medicare Diabetes Prevention Program (MDPP) expanded model would include "policies to further define the set of MDPP services, beneficiary eligibility criteria, and supplier eligibility and enrollment criteria," according to a CMS fact sheet. CMS also asks for comments on MDPP services and payment, supplier enrollment and administrative burden, and program integrity safeguards.
    • CMS continues its request for comments on how the overall Medicare system could be improved—input APTA already has provided in comments to other proposed rules.

    CMS has published a fact sheet on the proposed rule. APTA will submit comments on the proposed rule by the September 11 deadline, and will publish a PT-focused fact sheet when CMS issues a final rule sometime in late October or early November.

    Proposed Medicare Outpatient Payment Rule Allows Payment for TKA in Outpatient Settings, Increases Overall Payment by 2%

    If the proposed Medicare outpatient prospective payment system (OPPS) rule for 2018 gets adopted as-is, payment for total knee arthroplasty (TKA) will no longer be an inpatient-only arrangement, outpatient hospitals would see an overall 2% increase in payments, and ambulatory surgical centers could see a boost of nearly that much.

    APTA and other therapy groups are on record as supporters of the move toward reimbursement for outpatient-based TKA, though the association cautioned that the change would need to be accompanied by updated payment methodologies. Late last year, The New York Times described the possibility of the move toward outpatient-based TKA as one "sowing deep discord in the medical world."

    But CMS isn't stopping with TKA: the proposed rule also asks for comments on the possibility of removing total hip arthroplasty from inpatient status at some point in the future.

    The 2% payment increase to outpatient hospitals is an estimate based on a combination of a market basket update offset by adjustments related to productivity and cuts called for under the Affordable Care Act (ACA). While the increase is welcome, many hospital groups are concerned about other proposed changes that could negatively impact bottom lines, particularly a provision that would result in CMS paying 22.5% less than average sales prices for drugs purchased through the 340B program for "safety net" providers. Under the current rule, those providers receive payments that are 6% above average sale prices.

    Also of note in the proposed rule:

    • CMS would return to "non-enforcement" of direct supervision requirements for outpatient therapeutic services delivered in designated critical access hospitals and rural hospitals with fewer than 100 beds. It's a move designed to help rural hospitals recruit physicians, according to a CMS fact sheet on the proposed OPPS.
    • The Outpatient Quality Reporting Program would shed 6 measures, a change that CMS estimates will reduce administrative burden by 152,680 hours and save $6.5 million in reporting costs by 2020.
    • The mandatory startup of the Consumer Assessment of Healthcare Providers and Systems Outpatient and Ambulatory Surgery Survey would be delayed, though hospitals would be able to voluntarily report survey results next year.
    • Ambulatory surgical centers would receive an estimated 1.9% payment increase.
    • As in previous proposed rules, CMS also seeks input on how the overall Medicare system might be improved—an offer APTA took up in its comments to proposed rules earlier this year.

    APTA will review the OPPS proposed rule and submit comments on behalf of its members by the September 11 deadline. The association will provide a fact sheet on OPPS after the final rule is released later this year.