Scroll down the page to see what 2020 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 2020, 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 2020.) 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 2020 Medicare Physician Fee Schedule final rule that will affect the physical therapy profession in 2020 and beyond.
2020 Changes to Fee Schedule Payments
Effective for services provided on or after January 1, 2020, the 2020 fee schedule conversion factor is 36.09. CMS made minor adjustments to the values of CPT codes in the physical medicine and rehabilitation family. APTA's Medicare Physician Fee Schedule calculator will be updated as of January 1, 2020, to reflect the most up-to-date values issued by CMS and to help you better determine how your typical case-mix will fare.
2020 Therapy Threshold Amount
For 2020, 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:
- $2,080 for PT and SLP services combined, and
- $2,080 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 Medicare Payment Thresholds for Outpatient Therapy Services.
PTA Payment Differential Modifier
Therapist Assistant Modifiers
CMS finalized its proposal to establish a modifier to identify services provided by physical therapist assistants (PTAs) (along a similar modifier for occupational therapy assistants), as required by the Bipartisan Budget Act of 2018. Beginning January 1, 2020, claims from all outpatient therapy providers of PT services must include the CQ modifier for services furnished in whole or in part by a PTA.
The new modifier is appended on the same line of service as the PT therapy modifier GP, which remains unchanged.
For practitioners submitting professional claims under the PFS, the CQ modifier applies only to services of physical therapists in private practice; not to services furnished by or incident to the services of physicians or nonphysician practitioners ‒ including nurse practitioners, physician assistants, and clinical nurse specialists ‒ because PTAs do not meet the qualifications and standards of physical therapists. For providers submitting institutional claims and paid at PFS rates for their outpatient PT services, the CQ modifier applies to the following providers: outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies, and comprehensive outpatient rehabilitation facilities. However, the modifier is not applicable to claims from critical-access hospitals, because those providers are paid on a reasonable cost basis.
Definition of Services Furnished "In Part"
In the final rule, CMS established a de minimis standard of more than 10% for services delivered "in whole or in part" by a PTA. This definition was in response to feedback from APTA and other stakeholders on the agency’s proposed definition, which had been a service for which any minute of a therapeutic service is furnished by a PTA. For a quick reference, check out our PTA Modifier Guide (.pdf).
New codes: See APTA's 2020 Physician Fee Schedule Coding Updates article for information on the new trigger point dry needling codes, biofeedback codes, cognitive function intervention, and online digital assessment codes.
Evaluation and reevaluation codes: In 2020, Medicare is maintaining a single payment rate for all 3 tiered evaluation codes that were implemented in 2017. It continues to remain imperative that PTs 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
As part of overall efforts to move Medicare payment away from fee for service and toward a structure that holds providers accountable for patient outcomes and costs, CMS made significant changes to the home health and skilled nursing facility (SNF) payment systems. The SNF Patient-Driven Payment Model (PDPM) is effective as of October 1, 2019 (the start of fiscal year 2020), and the Home Health Patient-Driven Groupings Model (PDGM) (.pdf) is effective as of January 1, 2020.
Learn more about the new SNF and home health payment models and stay up-to-date on postacute care reforms by visiting our PDPM and PDGM webpage and our Medicare Postacute Care Reform webpage.
Home Health Review Choice Demonstration: 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.
It is anticipated that by May 4, 2020, the Review Choice Demonstration will be implemented in these 5 states. CMS will monitor the transition to PDGM and assess the need for any change to this date. CMS will continue to post additional information on its Review Choice Demonstration for Home Health Services webpage.
Affiliation disclosures: CMS will begin requiring providers and suppliers to disclose their affiliations with entities that have run afoul of Medicare, Medicaid, or CHIP rules. The requirement is intended to prevent sanctioned entities from reentering federal programs by using other entities as cover. Medicare, Medicaid, and CHIP providers now must disclose current or past affiliation with an organization that has uncollected debt, has had a payment suspension under a federal health care program, has been excluded from a federal health care program, or has had billing privileges denied or rescinded. If they don't disclose, CMS reserves the right to prevent them from participating in Medicare, Medicaid, and CHIP.
CMS defines "affiliation" to include only the following relationships having occurred in the last 5 years:
- Direct or indirect ownership of 5% or more in another organization.
- A general or limited partnership interest, regardless of the percentage.
- An interest in which an individual or entity "exercises operational or managerial control over, or directly conducts" the daily operations of another organization, "either under direct contract or through some other arrangement."
- An individual is acting as an officer or director of a corporation.
- Any reassignment relationship.
CMS will notify providers it has identified as having such an affiliation, and will require them to report all affiliations meeting the standard. Over time, CMS intents to increase the scope of providers required to report this information, but currently only providers and suppliers contacted directly by CMS need to disclose. CMS will update its Form CMS-855 applications to include an affiliation disclosure section.
For more information see the CMS Press Release or view the Final Rule (.pdf).
Regulatory Burden Reduction
APTA is actively involved in 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. For more information see the APTA Administrative Burden advocacy webpage.