Health care reform is swiftly moving providers and patients toward value-based payment and away from procedural-based, fee-for-service systems. To enable PTs and PTAs to be successful in this evolving environment, APTA has been actively pursuing payment alternatives as part of health care reform's triple aim of better care for individuals, lower costs, and better community health. The association's goal is to work with the federal government and payers to reform payment for outpatient physical therapist services to improve quality of care, recognize and promote the clinical judgment of the physical therapist, and provide policymakers and payers with an accurate payment system that ensures the integrity of medically necessary services. Below are areas of particular impact on PTs and PTAs.
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New Evaluation and Reevaluation CPT Codes
On January 1, 2017, the 3 tiered physical therapy evaluation codes and an updated reevaluation CPT code recommended by AMA and supported by APTA were launched. While the evaluation codes reflect 3 levels of patient presentation—low, moderate, and high complexity—the Centers for Medicare and Medicaid Services assigned the same value to all of them in the 2017 physician fee schedule. It remains important to accurately code the complexity of the PT evaluation, as the distribution of coding will be a factor in determining payment rates in the future.
Alternative Payment Models Under Medicare
Alternative payment models include the Comprehensive Joint Replacement Model (CJR), a new payment system being tested for episodes of care related to total knee and total hip replacements under Medicare. The initial CJR model began in April 2016, and will be expanded in 2018 to include hip and femur fractures. Similar models for cardiac care also will begin in 2018—mandatory bundling programs for care associated with bypass surgery and heart attacks. A cardiac rehabilitation incentive payment model also is slated to begin in 2018.
Medicare Quality Payment Program (QPP)
Enacted in April 2015, MACRA permanently repealed the flawed sustainable growth rate formula for determining Medicare payments for clinicians’ services and establishes a new framework for rewarding clinicians for value over volume. It also streamlined former quality-reporting programs such as the Physician Quality Reporting System into a single new system, the Merit-Based Incentive Payment System (MIPS). MIPS and Advanced Alternative Payment Models make up the 2 tracks providers can follow within MACRA's Quality Payment Program.
Medicare Postacute Care Reform
Physical therapist services represent a significant portion of Medicare Part A expenditures in postacute care settings, which include inpatient rehabilitation facilities, long-term care hospitals, skilled nursing facilities, and home health. Medicare is proposing reforms to the skilled nursing facility payment system, and is considering changes to how home health agencies are reimbursed as well. APTA strongly supports reform initiatives, such as the Improving Post-Acute Care Transformation Act of 2014—the IMPACT Act, that will ensure access to and comprehensive coverage of physical therapist services that are centrally focused on the postacute care patient's unique needs.