Scroll down the page to see what 2019 will bring related to the Quality Payment Program, Medicare physician fee schedule, and postacute care payment.
Continued Focus on Value
The Centers for Medicare and Medicaid Services (CMS) continues to shift away from the fee-for-service payment structure, in which providers are rewarded solely by the volume of services provided, and toward a structure that holds providers accountable for patient outcomes and costs. This move to value-based care is intended to advance the goals of health care's "triple aim"—improving the patient experience of care (including quality and satisfaction), bettering the health of populations, and reducing the per-capita cost of health care. Physical therapists (PTs) must quickly identify opportunities to become engaged in value-based payment models.
Value-based payment models often are referred to as alternative payment models (APMs). An APM is a payment approach that incentivizes providers to collaborate to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.
To navigate value-based payment, providers will need data. PTs will need to understand and promote the value they bring to the health care system and to the models in which they participate. Value in health care typically is expressed as quality (outcomes of care and patient experiences) divided by cost (direct and indirect). PTs need to know their outcome and cost data at the individual and practice level, as well as for the APM in which they participate, in order to determine how their performance and that of the group as a whole may affect payment.
To help PTs transition to value-based payment, APTA launched the Physical Therapy Outcomes Registry (Registry) in early 2017. The Registry enables PTs to make improved data-informed clinical decisions, track and benchmark outcomes against industry data, and demonstrate the value of physical therapist services. It directly integrates with EHR systems to seamlessly and securely transfer data to a database of patient episodes. The database provides immediate profession-wide benchmarking and informs future research. The Registry is now accepting facility enrollments, ranging from small private practices to large, multisite organizations.
To learn more about how to move into value-based payment models, see APTA's Value-Based Payment webpage. To learn more about contracting with APMs, please see the Alternative Models Under Medicare and Medicaid webpage.
The Quality Payment Program (QPP) rewards value and outcomes with incentives for eligible clinicians via 1 of 2 tracks: the Merit-based Incentive Payment System (MIPS) and Advanced APMs. Beginning in 2019, participation in QPP will be mandatory for certain PTs in private practice. Other private practice PTs will be eligible although not required to participate.
MIPS: PTs participating in MIPS earn a performance-based payment adjustment to their Medicare payment, based on a score derived from quality data in the Quality (from the former PQRS) and Improvement Activities categories. (MIPS also includes 2 other categories, Promoting Interoperability from the former Meaningful Use initiative and Cost, but PTs are exempt from these in 2019.) MIPS is the first large scale value-based payment model that will impact PTs. For PTs who are eligible but not required to participate, participation will be a business decision in which they must weigh the benefits of earning incentives with the risk for penalties. APTA has resources to help PTs navigate the MIPS program.
Advanced APMs: Advanced APMs are a subset of APMs that let clinicians and practices earn more for taking on risk related to their patient's outcomes. Clinicians may earn a 5% incentive payment by participating in an Advanced APM if they meet set minimums for the amount of Medicare Part B payments received or number of Medicare Part B patients treated through the Advanced APM. Most clinicians in Advanced APMs will be Qualifying APM Participants (QPs) and eligible to receive the incentive payment. Participating in an Advanced APM exempts clinicians from the MIPS program. A QP determination status lookup tool is available for eligible clinicians to review.
Learn more about specific Advanced APMs at the CMS Innovation Center website. APTA also has resources on APMs. For more on value-based care and payment, check out APTA’s comprehensive podcast series.
Medicare Physician Fee Schedule
The Centers for Medicare and Medicaid Services (CMS) issued several payment updates and policy changes in the 2019 Medicare Physician Fee Schedule final rule that will affect the physical therapy profession in 2019 and beyond.
2019 Changes to Fee Schedule Payments
Effective for services provided on or after January 1, 2019, the 2019 fee schedule conversion factor is 36.0463, which reflects the +0.25% statutory update factor reduced by the 2019 RVU budget neutrality adjustment of -0.12%. CMS made minor adjustments to the values of CPT codes in the physical medicine and rehabilitation family. Before January 1, 2019, APTA will update the Medicare Physician Fee Schedule calculator to reflect the most up-to-date values issued by CMS and to help you better determine how your typical case-mix will fare.
2019 Therapy Threshold Amount
For 2019, the threshold amount for using the KX modifier, which confirms that services are medically necessary as justified by appropriate documentation in the medical record, is:
- $2,040 for PT and SLP services combined, and
- $2,040 for OT services.
For information about the outpatient therapy threshold exceptions process and targeted medical review for annual amounts above $3,000, visit APTA's Payment for Medicare Therapy Services webpage.
PTA Payment Differential Modifier
Therapy Assistant Modifiers
CMS finalized its proposal to establish 2 new modifiers to identify services provided by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs), as required by the Bipartisan Budget Act of 2018. Beginning January 1, 2020, claims from all providers of PT and OT services must include these modifiers for services furnished in whole or in part by a PTA or OTA.
These new modifiers are be appended on the same line of service as the respective PT, OT, or SLP therapy modifiers (GP, GO, GN):
- CQ Modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant
- CO Modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant
The 3 therapy modifiers will continue in effect, unchanged, as follows:
- GP – services delivered under an outpatient physical therapy plan of care
- GO − services delivered under an outpatient occupational therapy plan of care
- GN − services delivered under an outpatient speech-language pathology plan of care
Definition of Services Furnished "In Part"
Responding to feedback from APTA and other stakeholders, CMS revised its proposed definition of a service that is furnished in whole or in part by a PTA or OTA, which had been a service for which any minute of a therapeutic service is furnished by a PTA or OTA. Instead, CMS defined a de minimis standard for "in whole or in part" as more than 10% of the service being furnished by the PTA or OTA.
CMS anticipates addressing application of the therapy assistant modifiers and the 10% standard more specifically, including their application for different scenarios and types of services, in rulemaking for 2020.
Note: The payment differential is applicable to services provided in private practice, outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies, and comprehensive outpatient rehabilitation facilities. It is not applicable to outpatient therapy services furnished by critical access hospitals.
Functional Limitation Reporting
The functional limitation reporting (FLR) program is discontinued as of January 1, 2019. One reason CMS gave for the decision was strong APTA regulatory and legislative advocacy efforts highlighting the heavy administrative burden despite little contribution to improved patient care. CMS is retaining the set of 42 nonpayable HCPCS G-codes until 2020, as this will allow time for therapy providers and other private insurers who currently use these codes for purposes of functional reporting to update their billing systems and policies. This will avoid unnecessary delays or denials of claims that inadvertently contain any of these G-codes during 2019.
Evaluation and Reevaluation Codes
In 2019, Medicare is maintaining a single payment rate for all of the 3 tiered evaluation codes that were implemented in 2017, saying it will continue to collect utilization data before considering any changes. This means it's imperative that PTs continue to document the medical necessity of their evaluations and accurately choose the appropriate codes, to ensure that Medicare has complete data for potentially striating payment rates in the future. APTA has resources to help you make the appropriate determinations.
Postacute Care Payment
The Medicare payment system is in the midst of a paradigm shift—away from the fee-for-service payment structure, in which providers are rewarded solely by the volume of services provided, and toward a structure that holds providers accountable for patient outcomes and costs. This move to value-based care is intended to advance the goals of health care's "triple aim."
As part of this effort, CMS finalized significant changes that will affect the hocme health and skilled nursing facility payment systems—beginning in FY 2020 for SNFs and CY 2020 for home health agencies. These payment systems align payment with patient characteristics and patient needs, and eliminate the connection between therapy utilization and reimbursement. CMS finalized the Skilled Nursing Facility Patient-Driven Payment Model (PDPM) and Home Health Patient-Driven Groupings Model (PDGM) in 2018.
Learn more about the new SNF and home health payment models and stay up-to-date on postacute care reforms by visiting our Medicare Postacute Care Reform webpage.
In May 2018, CMS issued a notice indicating its intention to re-launch a home health agency (HHA) pre-claim review demonstration project it had shelved in 2017. Now called the Review Choice Demonstration for Home Health Services, the demonstration initially will apply to HHA providers in Florida, Illinois, North Carolina, Ohio, and Texas, with the option to expand after 5 years to other states in the Medicare Administrative Contractor Jurisdiction M (Palmetto). The demonstration will give HHAs in the demonstration states 3 options: pre-claim review of all claims, postpayment review of all claims, or minimal postpayment review with a 25% payment reduction for all home health services.
The Review Choice Demonstration began December 10, 2018, in Illinois. No further information was given on the 4 other states originally named in the announcement, but CMS will give HHAs in those states at least 60 days advance notice. CMS will continue to post additional information on its Review Choice Demonstration for Home Health Services webpage.
Regulatory Burden Reduction
APTA is actively involved in a number of efforts to reduce administrative burden on physical therapists across settings. This includes efforts to address regulations and rules imposed by CMS as well as by commercial payers.
In addition to FLR being eliminated, PTs and PTAs can anticipate the following changes in CMS programs beginning in 2019:
- Elimination of the Functional Independence Measure (FIM) Assessment Tool in the Inpatient Rehabilitation Facility setting (Effective 10/1/2019)
- Reduction in the number of required assessments in the skilled nursing facility setting (Effective 10/1/2019)
- No requirement for a physician order for routine monitoring of vital signs incuding pulse oximetry, per a clarification from CMS in its Home Health Conditions of Participation Interpretive Guidelines.