Although APTA and others were caught off guard by CMS's decision in the final fee schedule ruling to adopt changes to the practice expense (PE) values of CPT codes that are the "bread and butter" of physical therapist practice, the association did not take it for granted when the proposed rule indicated that CMS would maintain the current PE values. And long before that, APTA has been aware of this and many other potential changes that are part of health care payment reform.
Here's a timeline of activities and events leading up to the final rule release in November 2017.
1994, 1995, 1998
The physical medicine and rehabilitation (PM&R) CPT codes are reviewed as a family of codes, the last such time until 2016. Traditionally, CPT codes are reviewed approximately every 5 years.
APTA begins work on developing proposals for a new payment system, following regulatory and legislative pressures, including the newly announced multiple procedure payment reduction (MPPR).
The APTA Board of Directors passes a resolution and statement to advance the work on a reformed payment model for outpatient physical therapy services.
MPPR goes into effect.
The Affordable Care Act requires the Centers for Medicare and Medicaid Services (CMS) to periodically identify and review potentially misvalued codes and make appropriate adjustments to the relative values of services identified as being misvalued.
An AMA CPT Editorial Panel work group convenes to address concerns in the 2011 proposed Medicare physician fee schedule (MPFS) related to the PM&R codes, which were brought forth by the providers that report those services. The work group's aim is to help those providers develop a proposal to better reflect the services provided in contemporary practice.
APTA conducts extensive work on pilot testing, surveying, and presenting potential new PM&R codes as part of its payment reform efforts.
The Protecting Access to Medicare Act expands from 7 to 16 the categories of services that CMS reviews for potentially misvalued codes, and establishes an annual target for reductions in PFS expenditures that result from the misvalued code adjustments.
The AMA CPT Editorial Panel work group on PM&R is disbanded and instructed to go through the CPT process for any code changes.
AMA requires APTA to submit an action plan for the upcoming review of potentially misvalued services.
July 7, 2016
CMS releases the proposed 2017 MPFS, which includes the anticipated review of potentially misvalued codes.
September 15, 2016
APTA and CMS leaders meet to discuss, among other issues, the potentially misvalued codes as introduced in the proposed MPFS.
APTA sends an AMA RUC survey to a sampling of members to solicit responses regarding their use of the potentially misvalued codes in practice, as part of data gathering for input into the AMA review.
APTA analyzes survey responses with member experts and consultants.
November 3, 2016
CMS releases the 2017 MPFS final rule, confirming it will include more information in its 2018 MPFS on how the potentially misvalued codes will be valued. The agency expects to receive valuation recommendations from the AMA RUC, and the AMA RUC will consider input from APTA based on the survey responses from October.
APTA submits work RVU and PE recommendations for each of the potentially misvalued codes to the AMA for its review board meeting in January.
January 1, 2017
Implementation of new PT evaluation codes.
RUC HCPAC reviews the 19 PM&R codes and 3 orthotics/prosthetics training/management codes. The HCPAC recognized the compelling evidence for increasing the work RVUs for several of the codes and made recommendations to do so. The AMA Practice Expense (PE) Subcommittee also put forth recommendations for the PE inputs for these same codes.
In anticipation of the proposed 2018 MPFS, APTA conducts an informal survey of selected sections and the Alliance for Physical Therapy Quality and Innovation to gain more insight into PTs' use of personnel and time spent providing 1-on-1 services.
April 12, 2017
APTA meets with CMS to discuss the shift in the utilization of physical therapy services from passive to active therapy, and the future of payment.
July 13, 2017
CMS releases the proposed 2018 MPFS. CMS proposes to adopt the RUC HCPAC recommendations for work RVUs but not to accept the PE input recommendations, instead maintaining the 2017 PE inputs. CMS states that had it used the recommended PE inputs, the 50% MPPR on the PE for these services would duplicate payment adjustments that already had been addressed by the RUC HCPAC.
APTA voices its strong support for the proposed rule in correspondence with CMS staff, collaborates with other therapy groups to convey a unified message of support to CMS in our comments, and provides members with a template comment letter, encouraging them to submit comments individually in support of the rule.
September 11, 2017
APTA, along with more than 50 individual PTs, submits comments supporting CMS's proposed values for the 22 CPT codes, emphasizing the importance of finalizing the codes' values as proposed.
November 2, 2017
CMS releases the 2018 MPFS final rule, adopting the work RVUs for the 22 codes as proposed. However—catching APTA and members completely off-guard—CMS reverses its proposal to maintain the 2017 PE values and instead adopts the RUC HCPAC recommendations for those values. CMS states that it was persuaded by the RUC HCPAC's reassurance that the PE committee considered the 50% MPPR in its recommendations. As a result, 10 of these 22 codes increased in value, and 12 decreased. Two that decreased (manual therapy and therapeutic exercise) are active, hands-on therapy services that make up the majority of services in orthopedic physical therapy clinics. While CMS estimates that the aggregate decrease is expected to be 2%, this percentage will vary based on patient case mix and billing patterns.
Summary of CMS responses to comments on the proposed rule:
CMS noted in the rule that many commenters agreed with their proposal to maintain the existing 2017 PE inputs for all 19 PM&R codes (plus the 3 orthotics/prosthetics codes). A number of these commenters noted the importance of the PE values that reflect the costs of maintaining a therapy practice (such as renting office space, buying supplies and equipment, and staff salary/benefits). Some of these commenters thanked CMS for recognizing that if the recommended inputs to develop the PE RVUs were adopted, the 50% MPPR on the PE for these services would duplicate the payment adjustments to account for efficiencies that had already been addressed through the code-level valuation process.
However, several commenters, including the RUC HCPAC, urged CMS to implement the recommended direct PE inputs. In its comments, the HCPAC assured CMS that the RUC PE Subcommittee understood the 50 percent MPPR and took it into account, in addition to the efficiencies of services billed together, when reviewing the direct PE inputs for these services.
January 1, 2018
New values for PM&R codes become effective.
For additional information and updates on APTA's responses, visit APTA's Medicare Physician Fee Schedule webpage. As of November 2017, APTA expects to meet with CMS leadership and staff to discuss concerns with the rule and ascertain what prompted CMS's reversal on the PE inputs. The association also is pursuing a congressional and/or regulatory fix to the devaluing of the manual therapy PE value.