Scroll down this page for info on topics including the Medicare fee schedule and therapy cap, SGR, PQRS, functional limitation reporting, and more.
New Year, New Changes
Following years of advocacy by physicians, physical therapists, and other health care professionals, Congress passed a bill to repeal the flawed SGR formula on April 14, 2015. The Medicare Access and CHIP Reauthorization Act of 2015 came a little more than a year after President Obama, on April 1, 2014, signed into law the Protecting Access to Medicare Act of 2014, the last in a long line of annual temporary "fixes" that prevented a large payment cut for physicians, physical therapists, and other health care professionals from taking effect. The 2014 law also extended the therapy cap exceptions process until March 31, 2015, and the April 14, 2015, repeal law further extends the exceptions process to December 31, 2017.
In addition, a number of changes included in the 2015 Medicare Physician Fee Schedule final rule affect physical therapist practice and payment for 2015.
Changes that are in effect regarding fee schedule payment rates include the following:
- From January 1-June 30, 2015, there is a slight change from 2014 in the conversion factor for providers. The 2015 conversion factor for the first 6 months is $35.7547 as mandated by legislation. (The 2014 conversion factor was $35.8228.) Effective July 1, 2015, there will be a .5% update to the payment rates for the remainder of the year and an extension of the existing 1.0 geographic practice cost index (GPCI) work floor.
Changes in effect regarding the therapy cap include the following:
- The therapy cap amount for 2015 is $1,940 (up from $1,920) for physical therapy and speech language pathology combined, with a separate $1,940 cap for occupational therapy.
- Providers may obtain an exception to the therapy cap until December 31, 2017.
As a result of the Medicare Access and CHIP Reauthorization Act, the manual medical review process at $3,700 is replaced with a new medical review process. Under this new process, CMS will determine which therapy services to review by considering factors. These factors would include: (1) reviewing providers with patterns of aberrant billing practices compared with their peers; (2) providers with a high claims denial percentage or who are less compliant with applicable Medicare program requirements; and (3) newly enrolled providers.
Medicare Payment Updates and Policy Changes
The Center for Medicare and Medicaid Services (CMS) has issued several payment updates and policy changes that will affect outpatient physical therapy and home health providers for calendar year 2015. These updates and changes are included in the Medicare Physician Fee Schedule, and Home Health Prospective Payment System.
APTA has developed the following final rule summaries for members:
Note: APTA's Fee Schedule Calculators have been updated for members to reflect 2015 payment rates. Review APTA's 2015 Medicare Therapy Cap FAQs posted to get information on the most commonly asked therapy cap questions.
Physician Quality Reporting System (PQRS)
Physical therapists will face changes to Physician Quality Reporting System (PQRS) measures specifications in the new year. There is a requirement for physical therapists in private practice to report 9 individual measures (or up to 8, if 9 measures are not applicable) via claims or registry under the PQRS program to avoid the 2017 2.0% payment penalty. There also are changes to the measure specifications for several PQRS measures.
The changes recently announced by CMS include changes to the medication measure, and the elimination of the low back pain and chronic wound care measures. PTs planning to participate in PQRS in 2015 are strongly encouraged to review the 2015 measures specifications, which contain information on how a measure is defined and how to report, and the qualifying case information that includes quality data codes for reporting. APTA has updated its PQRS resources to reflect the 2015 measures changes.
Functional Limitation Reporting
APTA has numerous resources to help you navigate functional limitation reporting, including an online complaint form for members in need of staff assistance.