• News New Blog Banner

  • Proposed 2014 Physician Fee Schedule Adjusts Payment Rates, Updates PQRS, Applies Therapy Cap to CAHs

    Today, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2014 Medicare physician fee schedule rule that updates 2014 payment amounts and revises other payment policies. Excluding the 24.4% projected sustainable growth rate payment cut, the rule’s aggregate impact on payment is a positive 1% for outpatient physical therapy services. Additional proposed policies that will impact physical therapists include updates to the Physician Quality Reporting System (PQRS) program, application of the therapy cap to critical access hospitals, and changes to the calculation of geographic practice cost indices.

    The law applies an annual beneficiary limit on outpatient therapy services for physical therapy and speech-language pathology services combined and a separate limit for occupational therapy services. Following the passage of the American Taxpayers Relief Act earlier this year, outpatient therapy services provided in critical access hospitals (CAHs) accrued toward the therapy cap amount for the first time. However, in 2013 CAHs are not subject to the therapy cap, meaning they currently do not have to report the KX modifier when the cap is exceeded or undergo manual medical review for services exceeding $3,700. The proposed rule would change this policy to apply the cap to outpatient therapy services furnished in CAHs in 2014 if Congress extends the therapy cap provision to hospitals in 2014.

    CMS proposes to retain the 12-month calendar year reporting period for the PQRS program in 2014 and beyond. The incentive payment for 2014 will remain 0.5%. The 2014 reporting period data will be used to inform both the 2014 incentive payment (0.5%) and the 2016 payment adjustment (-2.0%). CMS is proposing to make the following changes to the successful reporting requirements for 2014:

    • Increase the number of measures that must be reported via the claims and registry-based reporting mechanisms from 3 to 9
    • Change the threshold for reporting individual measures via registry to require that eligible professionals report on 50% of the eligible professional’s applicable patients rather than 80%
    • Eliminate the option to report on claims-based measures groups

    The proposed rule will be published in the July 19, 2013, Federal Register. The public will have until September 6, 2013, to submit comments in response to this rule, and APTA will submit comments on behalf of its members. After reviewing public comments, CMS will publish a final rule on or about November 1, which will become effective for services furnished during calendar year 2014. APTA will provide a more detailed summary of the rule in the upcoming week.

    Final Rule on Certain ACA Provisions Addresses Medicaid, CHIP

    A final rule on provisions of the Affordable Care Act (ACA) will impact physical therapists (PTs) as providers of services under Medicaid and the Children's Health Insurance Program (CHIP).

    Provisions of the final rule include:

    • New Medicaid eligibility provisions
    • Changes related to electronic Medicaid and CHIP eligibility notices and delegation of appeals
    • Updates that streamline existing Medicaid eligibility rules
    • CHIP revisions related to the substitution of coverage to improve the coordination of CHIP coverage with other coverage
    • Amended requirements to ensure that most alternative benefit plan (ABP) packages include essential health benefits and meet certain other minimum standards
    • Implementation of specific rules for insurance exchanges related to authorized representatives, notices, and verification of eligibility for qualifying coverage in an eligible employer-sponsored plan
    • Updates that simplify the complex Medicaid premium and cost-sharing requirements

    In addition, the rule addresses ACA's new optional eligibility group for low-income adults aged 19 to 64. Effective January 1, 2014, states that implement this new eligibility group must provide medical assistance for these adults through an ABP, except that individuals in the new group who meet the exemption criteria can choose between ABP benchmark benefits as defined by the state under the ACA rules and ABP benchmark benefits defined as the state's approved Medicaid state plan. Adults not meeting exemption criteria must be provided the 10 mandatory benefits that the ACA deemed "essential health benefits," one of which includes rehabilitative and habilitative services.

    States that do not opt for Medicaid expansion to this new group will not have to provide ABPs to this population. However, states have the flexibility to define different benefit packages to meet the needs of disparate populations. For example, states retain flexibility to continue to offer optional benefits, such as outpatient physical therapy services, to their Medicaid beneficiaries.

    APTA will post a summary of this final rule on the APTA website soon.

    Labels: None