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  • What's the Latest at CMS? Your Guide to Recent Proposed and Final CMS Rules

    The US Centers for Medicare and Medicaid Services (CMS) spent its spring and summer issuing proposed and final rules on areas ranging from the Medicare physician fee schedule, to what skilled nursing facilities will be paid and what they'll have to report, to inpatient reimbursement and home health episodes of care.

    Here's a quick guide to where some of these rules stand, and resources available from APTA—including an August 23 webinar focused on big changes CMS is eyeing for home health beginning in 2019 (11:30 am – 1:00 pm, ET). To register for the webinar email advocacy@apta.org.

    Medicare Physician Fee Schedule (MPFS)
    Status: Proposed; comments due September 11
    Resources: CMS fact sheet; PT in Motion News coverage
    The big news from the proposed MPFS for 2018 is that values for current procedural terminology (CPT) codes will be maintained—and a few even increased—after talk of the possibility that some of these codes were "misvalued." APTA is preparing comments on the proposed rule and has created a template letter for individual physical therapists (PTs) to send to CMS that covers both the proposed MPFS and more general Medicare issues.

    Home Health Prospective Payment System (HH PPS)
    Status: Proposed; comments due September 25
    Resources: CMS fact sheet; PT in Motion News coverage; August 23 webinar
    The fact that CMS will further reduce payment in 2018 by an estimated $80 million isn't exactly news—that cut is part of a series of reductions mandated by the Affordable Care Act (ACA). What is news is the CMS plan to reduce the unit of home health payments from 60-day to 30-day episodes of care, and to remove therapy service-use thresholds to make case-mix adjustments to HH payments in favor of "clinical characteristics and other patient information." Both of those changes would begin in 2019 under the proposed rule. APTA is preparing comments and is offering a webinar on August 23 from 11:30 am – 1:00 pm (ET) to outline the basics of the proposal and how to engage with CMS on the rule. To register for the webinar email advocacy@apta.org.

    Inpatient Prospective Payment System (IPPS)
    Status: Final; effective October 1, 2017
    Resources: APTA summary; CMS fact sheet; PT in Motion News coverage
    Acute care hospitals (ACHs) will see an estimated $2.4 billion increase in fiscal year 2018 (which begins October 1, 2017), while long-term care hospitals (LTCHs) will see a $110 million drop. Other highlights of the final rule include a CMS announcement that it will make medical record reviews a "low priority" when it comes to the requirement that physicians must certify that a patient admitted to a critical access hospital (CAH) will be discharged or transferred within 96 hours of admission, and the implementation of a 1-year moratorium on a policy that ties LTCH payment rates to ACH rates if an LTCH admits more than 25% of its patients from a single ACH. Another change: beginning in fiscal year 2019, CMS will include dual-eligibility status as a component in calculating penalties under the readmissions reduction program.

    Skilled nursing facility prospective payment system (SNF PPS)
    Status: Final; effective October 1, 2017
    Resources: APTA summary; CMS fact sheet; PT in Motion News coverage
    The final SNF PPS includes an overall 1% payment increase, changes to reporting requirements, and updates to the list of quality measures related to skin integrity, self-care, and mobility. CMS also will expand the window for its review of claims data related to potentially preventable 30-day readmissions. Previously CMS used a single year's worth of claims data; the rule expands that window to 2 years, an increase that CMS says will increase the number of SNFs with sufficient numbers of cases for public reporting.

    Inpatient Rehabilitation Facility Proposed Payment System (IRF PPS)
    Status: Final rule – effective October 1, 2017
    Resources: APTA summary, CMS fact sheet, PT in Motion News coverage
    Like SNFs, IRFs will see a 1.9% payment increase—about $75 million—for fiscal year 2018. The "60% rule"—a requirement that for an IRF to receive payment, 60% of its patients must require treatment for 1 or more of 13 conditions—has been adjusted to address diagnoses for patients with traumatic brain injury and hip fracture, as well as multiple trauma codes that didn't translate between ICD-9 and ICD-10. The new rule also requires IRFs to report standardized patient assessment data across 5 categories: functional status; cognitive functions; impairments; medical conditions and comorbidities; and special services, treatments, and interventions. Additionally, beginning in FY 2020, CMS will replace the current pressure ulcer measure with an updated version of the measure, an action that APTA supported in its comments.

    CMS Wants to Scale Back CJR Bundling Program for TKA, THA; Proposes Cancelling Bundle Program for Cardiac Care, Eliminating Expansion of CJR to Hip, Femur Fractures

    In brief:

    • Proposed rule would reduce the number of geographic areas required to participate in the Comprehensive Care for Joint Replacement (CJR) bundling model from 67 to 34
    • Low-volume and rural hospitals in all 67 areas would not be required to participate in CJR, but could do so voluntarily
    • Plans to implement a bundling model for cardiac care have been shelved, as are plans to expand CJR to include care of hip and femur fractures
    • Requirements for becoming a qualified provider in the CJR as an advanced alternative payment model would be broadened to include clinicians who don't have a financial arrangement with a facility but who are employed by the facility or have a contractual agreement

    The US Centers for Medicare and Medicaid Services (CMS) wants to significantly scale back the knee and hip joint replacement bundled care model and plans to cancel expansion of bundled care models to cardiac care and hip/femur fractures. The announcements were made as part of a package of proposals unveiled on August 15 that also includes some loosening of requirements for a provider to be considered as a "qualifying provider" under the joint replacement bundle program.

    The hip and knee bundle program, known as the Comprehensive Care for Joint Replacement (CJR) model, launched in 2016 as the first-ever attempt by CMS to mandate bundled care—in the case of CJR, that requirement applies to 67 different geographic areas covering some 800 hospitals. Under the proposed rule change, the number of geographic areas required to participate in CJR would drop to 34, leaving participation voluntary for all hospitals in the other 33 areas, or about 350 facilities. CMS estimates that 60 to 80 hospitals will choose to voluntarily participate. Hospitals that can and do decide to opt out of the program will have episodes beginning at any point during 2018 cancelled.

    In addition to reducing the number of geographic areas required to participate in the CJR, CMS is proposing that low-volume and rural hospitals in the remaining 34 areas also be switched from mandatory to voluntary participation.

    Per the same proposed rule, CMS would cancel a planned expansion of mandatory bundling to cardiac care, as well as expansion of the CJR to include care for hip and femur fractures. Those expansions originally were set to be put in place in February of this year but were later delayed until October 1, and then pushed back again to a January 2018 startup date. The proposed rule effectively would cancel the programs.

    As CMS taps the brakes on the CJR, it also proposes making it easier for clinicians to be included as qualifying participants in the bundling program. Under the proposed rule, providers—including physical therapists—who don't have a financial arrangement with a facility in the CJR program, but who are either directly employed or contractually engaged with a participating hospital, would be accepted into the program. It would be up to the hospitals to supply CMS with an "engagement list" of those providers, and CMS would take it from there, using Medicare Part B claims data to decide whether a clinician can be considered an advanced alternative payment model qualifying provider. Clinicians who get the nod from CMS would not be required to report to under Merit-Based Incentive Payment System (MIPS) and could be eligible for payment bonuses up to 5%. (Because physical therapists are solely voluntary participants in MIPS as of now, they wouldn’t be subject to the MIPS reporting requirement even if they don’t participate in an advanced APM—but that could, and is expected to, change in future years.)

    CMS has issued a fact sheet on the proposal. APTA staff are reviewing the proposed rule and will provide comments by the October 15 deadline.

    The Good Stuff: Members and the Profession in Local News, August 2017

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

    Ashleigh Dalton PT, DPT, cofounder of Camp Cliffview, talks about how the program provides opportunities for children with special needs. (BlueRidgeNow.com)

    Jessica Dufault, PT, explains how addressing separation of abdominal muscles in women post-birth requires more than an exercise or 2. (Offspring.lifehacker.com)

    Jan Dommerholt PT, DPT, gives Good Morning Washington a glimpse of what exergaming is all about. (Good Morning Washington)

    Tom Hulst, PT, MHS, and Jen Kurnowski, PT, discuss dry needling for back pain. (West Michigan Fox 17 News)

    The Brenau University physical therapy program's pro-bono physical therapy clinic in Georgia, is benefitting students and patients. (Gainesville, Georgia, Times)

    Caitlin Jones, PT, DPT, talks about the progress of a remarkable 5-year-old recovering from a gunshot wound. (WSB-TV2, Atlanta, Georgia)

    Eric Robertson, PT, DPT, provides insight on how exercise can help keep back pain from becoming chronic. (Oprah.com)

    University of Mary, North Dakota, PT students work with engineering students to create adaptive cars inspired by the Go Baby Go program. (Bismarck, North Dakota, Tribune)

    "Jonathan continues to recover from his accident, and Laura continues to stand beside him as he does. One day, Laura was shadowing Jonathan's physical therapy session when his therapist invited her to help lift him out of his wheelchair. 'As soon as we got him up, he started kissing my neck,' Laura said. 'We hadn't been able to stand and hold each other since before the accident ... It gave me the chills. You don’t realize how much that means until it’s almost taken away from you.'" - Laura Browning Grant, whose husband, Jonathan, is recovering from an automobile accident, on the viral video of their first kiss in months. (Self.com)

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