In this review:
The big picture: CMS finalizes a policy for determining when services are delivered "in part" by a PTA; is hanging on to a plan to reduce payment to PTs and a host of other professions in 2021.
APTA and the physical therapy profession won a major concession from CMS, but continue to face a challenge in the final 2020 physician fee schedule (PFS). While the agency seems to have listened to critics and made significant positive changes to the way it will be calculating payment when therapy services are delivered "in part" by a physical therapist assistant (PTA), it inexplicably ignored thousands of comments, including a letter from members of Congress, calling for reconsideration of a proposed 8% payment cut for physical therapy payment and host of other disciplines in 2021.
To comply with federal law requiring 2 new code modifiers to denote services at least delivered "in part" by a PTA or occupational therapy assistant (OTA), CMS had established modifiers CQ and CO, respectively, in the 2019 PFS. In the same rule, CMS also forwarded a policy that created a "de minimis" 10% standard that would trigger use of the modifier whenever a PTA or OTA provided outpatient therapy services for 10% or more of the time spent furnishing the service. For the 2020 PFS, CMS had proposed that, among other things, the modifiers be applied to the claim when services were delivered concurrently with a physical therapist (PT), and all codes were to be accompanied by a written explanation of why the modifier was or wasn't used.
After an intensive advocacy effort from APTA and its members, CMS reconsidered its approach, adopting a system more consistent with many of the association's recommendations. Among the positive changes in the new rule:
- When the PT is involved for the entire duration of the service and the PTA provides skilled therapy alongside the PT, the CQ modifier isn't required.
- When the same service (code) is furnished separately by the PT and PTA, CMS will apply the de minimis standard to each 15-minute unit of codes—not on the total PT and PTA time of the service, as proposed, allowing the separate reporting, on 2 different claim lines, of the number of units to which the new modifiers apply and the number of units to which the modifiers do not apply.
- The proposed new documentation requirements are scrapped.
To summarize the final policy:
- Only the minutes the PTA spends independent of the PT counts toward the 10% de minimis standard.
- The de minimis standard is applied to untimed codes and is applied to each billed unit of a timed code rather than to all billed units of a timed code.
- If a PTA's time spent furnishing care exceeds 10% of the total time spent furnishing an untimed code, the CQ modifier is applied.
- If a PTA's time spent furnishing care exceeds 10% of a unit of service, the CQ modifier is applied to the unit.
- If a PTA provides 10% or less of each unit of the service, the CQ modifier is not applied.
Proposed payment cut
In an attempt to increase code values for office/outpatient evaluation and management (E/M) codes while maintaining the budget neutrality of the PFS, CMS proposed cuts to other codes to make up the difference. This change in code valuations would be effective January 1, 2021. Under the plan, physical therapy could see code reductions that may result in an estimated 8% decrease in payment. Other professions stand to lose as well: for example, ophthalmology would see a 10% cut, audiology would face a 6% reduction, chiropractic care would drop by 9%, and clinical social workers would see payment decline by 6%. In total, 36 specialties are facing payment reductions in 2021. However, CMS has not yet determined the actual cuts to each code.
Despite a strong reaction against the plan—more than 10,000 responses from the physical therapy profession alone—and a collaborative advocacy effort among professional organizations that included a letter signed by 55 members of Congress opposing the cuts and a provider sign-on letter signed by 10 associations, CMS left the proposal untouched in the final rule. The agency does briefly acknowledge the opposition and writes that a final determination won't be made until after further discussion and an evaluation of how other policy adjustments might affect the PFS budget in 2021.
Merit-based Incentive Payment System (MIPS)
The final rule also makes changes to the Merit-based Incentive Payment System (MIPS). Starting in 2020, CMS will add measures for diabetic foot and ankle care; peripheral neuropathy: neurological evaluation and prevention evaluation of footwear; screening for clinical depression and follow-up plan; falls screening and plan of care, elder maltreatment screen and follow-up plan; preventive care and screening: tobacco use: screening and cessation intervention; dementia: cognitive assessment, functional status assessment, and education and support of caregivers for patients with dementia; falls: screening for future fall risk; and functional status change for patients with neck impairment. The rule also removes 2 measures: pain assessment and follow-up, and functional status change for patients with general orthopedic impairments.
Other changes to MIPS include:
- Data completeness for the 2020 performance year will be set at a 70% sample for both Medicare Part B claims-based reporting and clinician or group reporting via a registry.
- Groups will be able to attest to an improvement activity when at least 50% of the MIPS-eligible clinicians perform the activity, at a rate of at least 50% of the group's providers with a National Provider Identifier (NPI) performing the same activity for the same 90 continuous days in the performance period.
- The Promoting Interoperability category will continue to be reweighted for PTs by CMS in 2020.
- MIPS-eligible clinicians with a final score of 45 will receive a neutral payment adjustment in 2020, with the score rising to 60 points for the 2021 payment year. The exceptional performance bonus will be triggered with a score of 85 points in both 2020 and 2021.
- CMS will also continue its shift to a streamlined version of MIPS, which it has dubbed "MIPS Value Pathways," (MVPs) for 2021 and beyond.
Also notable in the final rule:
- KX modifier: The threshold amount for use of the KX modifier will rise from $2,040 to $2,080 for physical therapy and speech-language pathology services combined, and by the same amount for occupational therapy services. The medical review threshold remains at $3,000. These changes will be incorporated into APTA's multiple procedure payment reduction (MPPR) calculator, which will be live before January 1, 2020.
- Dry needling: The final rule adds 2 dry needling codes (20560, needle insertions without injections in 1-2 muscles, and 20561, needle insertions without injections in 3 or more muscles), but CMS classified the codes as noncovered Medicare services unless a national coverage determination says otherwise. If the codes were covered, CMS believes they should be considered as "sometimes therapy" procedures rather than "always therapy."
- Biofeedback: CPT code 90911 (biofeedback training) was replaced with 2 codes: 90912, biofeedback training, initial 15 minutes of one-on-one patient contact; and 90913, biofeedback training, each additional 15 minutes of one-on-one patient contact. CMS clarified these as “sometimes therapy” procedures.
- Negative pressure wound therapy: CMS established relative value units (RVUs) and direct practice expense inputs for codes associated with negative pressure wound therapy, with a .41 work RVU for code 97607 (vacuum-assisted drainage collection for total wound surface area of 50 square centimeters or fewer) and .46 work RVU for 97608 (vacuum-assisted drainage collection for total wound surface area of 51 square centimeters or more).
- Online Digital Assessments: CMS established payment for 3 new HCPCS codes, G2061, G2062, and G2063, to describe qualified nonphysician health care professional online assessment and management services. These services are considered patient-initiated digital communications requiring a clinical decision that otherwise typically would have been provided in the office.
- Remote physiologic monitoring: In response to APTA's continued request for clarity from the agency as to whether PTs can engage in remote physiologic monitoring (RPM) services that include establishing, implementing, revising, and monitoring a specific treatment plan for a patient related to 1 or more chronic conditions that are monitored remotely (CPT codes 99453, 99454, 99457, and 99458), CMS stated in the final rule that it will "consider these and other questions related to RPM in future rulemaking." CMS has advised APTA that PTs with billing questions related to these codes should contact their Medicare Administrative Contractor(s).
- CMS denial or revocation of enrollment: CMS expanded its authority to deny or revoke a physician's or other eligible professional's Medicare enrollment. The new regulations permit CMS to revoke or deny, as applicable, a physician's or other eligible professional's enrollment if the provider has been subject to prior action from a state oversight board, federal or state health care program, independent review organization determination(s), or any other equivalent governmental body or program that oversees, regulates, or administers the provision of health care with underlying facts reflecting improper professional conduct that led to patient harm. In determining whether a revocation or denial on this ground is appropriate, CMS will consider several factors, including the nature of patient harm, the nature of the professional's conduct, and the number and types of sanctions or disciplinary actions imposed against the professional.