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  • The Post-Therapy Cap System: 5 Basics You Need to Know

    When Congress adopted a federal spending package that included the elimination of the hard cap on Medicare therapy services, it didn't just remove a rule—lawmakers also adopted a new system of payment thresholds and triggers, and a differential payment rate for physical therapist assistants (PTAs) and occupational therapy assistants (OTAs), among other things.

    APTA supported an end to the hard cap, which is a significant win for the most vulnerable Medicare patients, but other parts of the system that replaced it are problematic.

    The elimination of the hard cap is retroactive to January 1, 2018, but not all details of the post-cap system have been worked out, and it's possible that some may change before their implementation dates. In the meantime, here are the basic elements of the new system.  

    1. It boils down to a threshold for using KX modifiers and a trigger for possible medical review.
    The basic idea is this: outpatient therapy under Medicare now has a $2,010 threshold; services delivered beyond that require a KX modifier indicating that the service meets the criteria for a payment exception. When therapy reaches $3,000, it's subject to possible targeted medical review—although CMS didn't receive any additional funding to conduct these reviews.

    2. Physical therapy and speech-language pathology still are lumped together in the thresholds.
    Just as in the previous payment system that included a hard cap and exceptions process, the new system doesn't separate physical therapy from speech-language pathology in establishing thresholds. Those $2,010 and $3,000 limits are for physical therapy and speech-language pathology therapy combined—another element opposed by APTA.

    3. The thresholds apply to all part B outpatient therapy services—including services provided by hospital outpatient departments.
    For the brief time beginning in January when the therapy cap was in place, hospital outpatient facilities were not subject to the cap. That changed with the adoption of the budget package, and now these departments or clinics are subject to the thresholds: $2,010 for use of the KX modifier and $3,000 for potential targeted medical review.

    4. The PTA payment differential will start in 2022—along with a special claims designation.
    In the post-cap payment system, outpatient therapy services performed by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) will be reimbursed at 85% of the Medicare physician fee schedule—a change opposed by APTA. However, that's not set to happen until 2022.

    For now, claims do not include a way to designate whether a service was delivered by a PTA, but that too will change by 2022, when CMS will develop a modifier to make that distinction. Between now and then, look for opportunities to comment on proposed rules around this process, along with guidance and more details as they develop.

    5. Home health also will be subject to the PTA payment differential, absent a plan of care.
    The 85% payment differential for services provided by a PTA or OTA will apply to home health care provided to Medicare part B beneficiaries—but only when a home health plan of care is not in effect. The budget deal that resulted in the end to the hard cap also established other new rules for home health.PT in Motion News recently reported on these additional changes.

    CMS Offers Settlement Option for Providers With Denial Appeals in Limbo

    The US Centers for Medicare and Medicaid Services (CMS) is offering some providers a chance to settle backlogged claims denial appeals at 62% of net allowed amounts, but there are limits and deadlines involved.

    Called the "Low Volume Appeals Initiative," the program is part of a CMS attempt to clear a glut of Medicare appeals piling up at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council levels.

    The program is limited to providers who have fewer than 500 appeals with no single appeal exceeding $9,000. Providers begin the process by submitting an "expression of interest" form to CMS. Providers with National Provider Identifiers (NPIs) ending in an even number have from between now and March 9 to turn in the form; the window for providers with NPIs ending in odd numbers will open on March 12 and close on April 11.

    To qualify for the settlement, the appeal must meet certain criteria:

    • The appeal was pending before the OMHA and/or council level of appeal as of November 3, 2017.
    • The appeal has a total billed amount of $9,000 or less.
    • The appeal was properly filed at the OMHA or council level as of November 3, 2017.
    • The claims included in the appeal were denied by a Medicare contractor and remain in a fully denied status in the Medicare system.
    • The claims included in the appeal were submitted for payment under Medicare Part A or Part B.
    • The claims included in the appeal were not part of an extrapolation.
    • The appeal is still at the OMHA or council level of review when an administrative agreement is fully executed.

    The final agreement would cover all claims that are approved for settlement. Once finalized by CMS and the provider, Medicare Administrative Contractors (MACs) will total the claim amounts and make a single total payment within 180 days of CMS' signature on the agreement.

    Questions about the initiative can be emailed to MedicareSettlementFAQs@cms.hhs.gov.

    Home Health Faces Challenges in Wake of Budget Deal

    A major advocacy issue for the physical therapy profession was resolved with the elimination of the hard cap on therapy services under Medicare, but other provisions in the massive budget bill that ended the hard cap have created different challenges. Case in point: in the home health arena, patients and providers are facing budget cuts and a reduction in payment units, with the possibility of even more dramatic—and potentially damaging—changes to come.

    The final budget package approved by Congress last week includes provisions reducing the home health care unit of payment to 30 days from its current 60-day unit. In addition, the home health market basket percentage—the amount of money CMS plans devote to goods and services in a particular area—will be 1.5%. Both changes are slated to start in 2020, and other potential harmful moves could be on the horizon. The changes, opposed by APTA, were included late in lawmakers' negotiations around the budget deal with no opportunity for input from stakeholders. The new provisions also eliminate therapy thresholds that affect episode payment calculations.

    The payment unit changes echo provisions included in CMS' failed attempt to adopt what it called the Home Health Grouping Model (HHGM), a sweeping overhaul of the home health payment system proposed the summer of 2017. APTA and other groups opposed nearly all of the proposals associated with HHGM, including the switch to the 30-day payment unit. In a letter to CMS, APTA described the 30-day unit as a change that would produce a "perverse financial incentive for providers to inappropriately decrease lengths of stay and/or avoid admitting patients who will require care beyond the 30-day episode." CMS dropped its efforts to adopt HHGM in the fall.

    Although the 30-day unit adopted in the budget deal is similar to what was proposed in HHGM, there's 1 major difference: the provision now in place is budget-neutral. The 30-day unit proposed by CMS through the HHGM would have resulted in significant reductions in reimbursement.

    But that doesn't mean the ideas behind HHGM are dead. In fact, says Kara Gainer, APTA's director of regulatory affairs, the budget deal also includes a provision directing the Department of Health and Human Services (HHS) to develop a new case-mix system that can be implemented by 2020. The concern of APTA and other home health supporters is that HHS will resurrect many of the changes proposed in the HHGM.

    "We expect that HHS will attempt to create a case-mix system similar in nature to the HHGM," Gainer said. "However, HHS has said that its revisions will be based on feedback from a technical expert panel." That panel met on February 1 and included a representative from APTA. Gainer is hoping that at least 1 more panel meeting will be held in 2018.

    So does Diana Kornetti, PT, MA, president of the APTA Home Health Section. Kornetti is also a credentialed home care coding specialist.

    "Right now, it appears that only 1 technical expert panel meeting is required by law during 2018, and that's already happened," Kornetti said. "This is the first thing that needs to change. There is no guarantee that the home health industry and its stakeholders will have any future opportunity to review and discuss the issues and concerns that will arise."

    According to Kornetti, should stakeholders get that opportunity, the case for the right kinds of changes to the home health payment will be much stronger if it's backed by documented outcomes for physical therapy.

    "Patient acuity is critical," Kornetti said. "Capturing correct and thorough data, using objective measures, will be increasingly important to establishing an accurate payment for physical therapist services. We must speak the language of outcomes moving forward as a profession—our services must show our impact on reduction of costs, while continuing to strive for increasing clinical quality."

    With the therapy cap issue settled, APTA will focus its advocacy efforts in different ways, Gainer explained. The threats to home health will be 1 of the association's targets.

    But as with any other attempt to get policymakers to listen, the effort will require participation from physical therapists and physical therapist assistants, Kornetti added.

    "A key principle in our code of ethics speaks to advocacy for those we serve," Kornetti said. "It has never been more important for the postacute physical therapist and physical therapist assistant to become informed and participate in this process. One rung of our ladder toward a fully autonomous profession is having representation at the table where decisions are being made."

    CMS Issues Coding, Other Details on Supervised Exercise Therapy for Peripheral Artery Disease

    US Centers for Medicare and Medicaid Services (CMS) has released details on how it will process claims made as a result of its decision to cover supervised exercise therapy (SET) in the treatment of peripheral artery disease (PAD).

    The expansion covers physician-referred SET for up to thirty-six 30- to 60-minute sessions over a 12-week period. The sessions must be conducted in a physician's office or outpatient facility, and must be delivered by "qualified auxiliary personnel" that includes physical therapists, nurses, and exercise physiologists. Supervision is to be conducted by a physician or "non–physician practitioner"—a physician assistant, or nurse practitioner/clinical nurse specialist.

    Although CMS announced the change in May 2017, it only recently released the nuts-and-bolts around provider coding and claims processing for Medicare Administrative Contractors (MACs). Details are available from 3 resources:

    To receive coverage for SET, Medicare beneficiaries with PAD must have a face-to-face visit with a physician and be referred for the program. The physician visit must also include education on cardiovascular disease and PAD risk reduction. Medicare Administrative Contractors can allow for more sessions or a second set of 36 sessions, but these additional sessions require another referral.

    Making Transformation Possible: Panelists at APTA Event Explore Paths Toward Rethinking Pain Management

    Ending the opioid crisis—or even just making a dent in it—is going to require nothing less than transforming an entire culture's attitudes about pain and its management. But panelists at a recent APTA event believe there are models and concepts out there that provide hope for a future in which multidisciplinary nondrug approaches to pain replace an opioid prescription as the norm in health care.

    At its February 5 live event, "Beyond Opioids: Transforming Pain Management to Improve Health," APTA brought together 7 panelists with a range of perspectives, from a patient whose multiple surgeries were accompanied by opioid prescriptions, to a physical therapist (PT) who works in a program that educates and empowers patients to take more control of their pain, to a congressman who is fighting to raise public awareness of addiction as a disease. The entire conversation was broadcast live on Facebook, and a recorded version is available for viewing.

    Though each speaker brought something different to the table, a few common threads emerged when it came to what it will take to truly address the opioid epidemic, particularly as it relates to pain management. Panelists tended to emphasize the need for increased and more open communication, better identification of risk factors for opioid abuse, greater use of multidisciplinary approaches to pain management, and the need for more education delivered to patients, providers, employers, and entire communities.



    Panelist Joan Maxwell's story served as a touchpoint for the night, highlighting the patient experience and bringing current weaknesses in pain management into sharp relief. Maxwell's journey as a patient began with a double mastectomy, which led to a staph infection and subsequent surgeries—9 in all over fewer than 3 years. Along the way, Maxwell experienced a stroke. And at every juncture, she was prescribed opioids, with few conversations about what to expect in terms of pain and what other ways her pain might be managed.

    Luckily for Maxwell, who is now a patient and family advisor for John Muir Health and patient-member of Patient & Family Centered Care Partners Inc, she was able to avoid addiction. Her brother-in-law, however, was not as fortunate: over the course of what Maxwell described as "2 failed back surgeries," he became addicted to opioids. His wife administers his drugs and is careful to hide the medications from him.

    "He was just a regular person like all of us," Maxwell said, "but just 1 surgery, and he was addicted."

    Maxwell holds out hope that things can change for the better, beginning with more conversations between providers and patients about pain.

    Both Grant Baldwin, director of the division of unintentional injury prevention for the Centers for Disease Control and Prevention, and Rep Donald Norcross (D-NJ) echoed Maxwell's call for better communication, albeit in slightly different settings. Baldwin told the audience that more outreach is needed to spread the word about the CDC's guidelines for chronic pain management and its recommendations for nondrug approaches as a first-line treatment, while Norcross spoke about the need for better communication to lift the stigma around addiction and help communities and the federal government focus on a disease model.

    Norcross even offered advice about getting the message out.

    "Make an appointment when your congressman or congresswoman is in your district, and give the real story," Norcross said. "This is not some urban issue that happens in the dark of night. This can happen anywhere."

    As medical director of Swedish Pain Services and president of the American Academy of Pain Medicine, Steven Stanos, DO, brought firsthand knowledge of the latest approaches to pain management. Stanos outlined an intensive multidisiciplinary process at Swedish Pain Services that involves PTs, occupational therapists, pain medicine specialists, pain psychologists, and nurses in group and individual treatment settings. Although Stanos admitted that it's a system not available to everyone, and cost can be challenging for some patients, patients everywhere should be wary of treatment that relies on pain medications only.

    "I always think that [the presence of an opioid prescription] is a marker that [patients] didn't have comprehensive care," Stanos said. "A lot of [what needs to change] is about education and unlearning maladaptive ideas."

    Sarah Wenger, PT, DPT, is doing just that through a "Power Over Pain" program that emphasizes individualized approaches to management, with a focus on education and honest conversations with patients. Wenger is a board-certified clinical specialist in orthopaedic physical therapy and an associate clinical professor at Drexel University's College of Nursing and Health Professions.

    In many instances, Wenger explained, patients need to come to grips with the idea that they may always experience some degree of pain—"I don't think zero pain is particularly realistic for any of us," she added—but that they can be empowered when they understand how to manage pain in healthy ways. "The truth is, most people don't feel really great on opioids," Wenger said.

    Echoing previous panelists’ emphasis on communication were the final 2 speakers, Tiffany McCaslin and Bill Hanlon, PT, DPT, who also is a board-certified clinical specialist in orthopaedic physical therapy. McCaslin, a senior policy analyst for the National Business Group on Health, sees a need for employers to come to grips with the impact opioids and opioid-based pain treatment is having on employees and, in turn, on the overall operation of the business itself. The concept is at the heart of a new summit program being rolled out by her organization. "We're pressing on our members to take a look at this issue with eyes wide open" and to reduce the stigma around addiction, McCaslin said.

    As a PT working in addiction recovery at the St Joseph Institute in Port Matilda, Pennsylvania, Hanlon often finds himself helping patients who have suffered from a pain treatment system that relies too heavily on opioids. But that's not the entire patient population, he explained—many of the individuals he helps don't have underlying pain but experience it for the first time in the form of withdrawal symptoms.

    In either case, he said, communication and a multidisciplinary approach are key.

    "The way we approach addiction needs to be multidisciplinary, just as the approach to managing pain needs to be multidisciplinary," Hanlon said. "And as we get all the disciplines involved and understand the psychology of the person…we can help them more and more."

    But according to Hanlon, that multidisciplinary help must begin with helping a patient to understand what's possible—without an overreliance on opioids.

    "It's about communicating with people," Hanlon said. "It's talking with people and letting them experience the wellness."

    'Choose More Movement and Better Health': APTA Releases New #ChoosePT Video

    Anyone can experience pain—but nobody should feel trapped by opioids as the only way to manage it: that's the message at the heart of APTA's newest video public service announcement (PSA) in the #ChoosePT opioid awareness campaign.

    The new PSA, which debuted during a live panel discussion on pain management, features a teenaged boy, an adult woman, and an older man each experiencing pain, attempting to manage the pain through opioids alone, and ultimately making progress with physical therapy.

    "Pain is personal, but treating pain takes teamwork," the voiceover says. "When it comes to your health, you have a choice—choose more movement and better health. Choose physical therapy."

    The PSA is part of the association's national public awareness campaign, #ChoosePT, which has won multiple national awards, including best video for the first public service announcement.

    APTA's first #ChoosePT PSA reached more than 377 million Americans via television and radio in its first year of release, and APTA’s official consumer information website, MoveForwardPT.com, was visited by more than 3.2 million users in 2017.



    BuzzFeed Features Physical Therapy 'Success Stories'

    How about a little good news? Specifically, how about a little good news from patients who credit physical therapy and their physical therapists (PTs) for transforming their lives?

    Recently, BuzzFeed published "9 Physical Therapy Success Stories That'll Make You Choke Up A Bit," a collection of first-person accounts from patients who faced a range of issues including spine facture, labrum tears, recovery from a coma, and interstitial cystitis. The reason for the project, according to BuzzFeed, was to "inspire others who are currently recovering from pain, injuries, surgery, or other problems."

    A few choice quotes from contributors:

    "Thanks to physical therapy, I am now able to postpone [knee] surgery for at least 5 years without risking harm. Even though it may be hard, physical therapy is worth it in the end."

    "It was difficult and scary, but I can honestly say physical therapy saved my life."

    "My advice to all of you is to listen to your PT and trust them."

    "Once specific thing: PTs and [occupational therapists] need more recognition and props. They have to work really hard to get some of us back to some sort of norm."

    "I owe [my physical therapist] my mobility and my life without pain."

    In Wake of Nassar Conviction, PT Points to Need for Patient Education on Legitimate Pelvic Physical Therapy

    The multiple sexual abuse convictions of former USA Gymnastics doctor Larry Nassar brought an end to Nassar's monstrous behavior, increased awareness about systemic problems that allowed the abuse to occur, and hopefully even provided a certain sense of closure to the more than 150 victims of his assaults. But in an article written for the HuffPost, APTA member Lora "Lori" Mize, PT, DPT, and certified clinical specialist in women's health physical therapy, raised concern that the Nassar case also may create a ripple effect that could discourage individuals from seeking legitimate and responsibly delivered pelvic physical therapy.

    In her opinion piece titled "Nassar's Atrocities Stigmatize A Legitimate Medical Treatment," Mize contrasts Nassar's horrific actions with the well-established, evidence-based pelvic physical therapist treatments "performed by a highly trained specialist [that] can have a positive impact on a woman's quality of life."

    "It is my duty to women [in need of pelvic physical therapy] to ensure Nassar's abuse does not, in addition to all the other damage it has done, prevent others from getting the care they need," Mize writes. "It is critically important for women's health professionals to ensure the horror of the Nassar case does not feed public fear and misconceptions about pelvic [physical therapy] or stop women who need health care from walking through our doors."

    "This is a powerful article," said Patricia Wolfe, PT, MS, president of APTA's Section on Women's Health. "Lori did an excellent job articulating the value of pelvic physical therapy and its significant impact on quality of life

    Mize delivers the pelvic physical therapy message not only through an explanation of the relationship between pelvic floor muscles and their role in health, but also by way of examples from her own practice. She also clarifies what patients should expect from legitimate pelvic physical therapy treatment.

    “As Lori pointed out, what’s needed is clear and accurate communication to the public to encourage and inform individuals about legitimate care," Wolfe said. "That includes care related to incontinence, sexual dysfunction, constipation, and abdominal and pelvic pain.”

    "For women with pelvic floor disorders, it is difficult enough to battle the stigma, shame and guilt often associated with these conditions," Mize writes." Those of us who care for and care about the health of women and girls must not allow predators like Nassar to further victimize women by making them fear the very interventions that can improve and enrich their lives."

    Mid-Atlantic, Pacific States and Territories Will be First to See New Medicare Cards

    New Medicare cards are coming beginning this April, and, along with them, new beneficiary identifiers that don't rely on social security numbers (SSNs).

    According to recent information from the US Centers for Medicare and Medicaid Services (CMS), Medicare beneficiaries in 9 states, the District of Columbia, and 3 US territories will be the first to receive the new cards: Alaska, American Samoa, California, Delaware, District of Columbia, Guam, Hawaii, Maryland, Northern Mariana Islands, Oregon, Pennsylvania, Virginia, and West Virginia. CMS will begin mailing cards to those recipients in April. New cards in the remaining states and territories will be mailed beginning in June.

    The new cards will feature a unique Medicare identification number that will help CMS move away from health insurance claim numbers (HICNs) that contain the beneficiary's SSN and toward a CMS-generated Medicare beneficiary identifier (MBI). The change, intended to thwart fraud, was required by provisions in the Affordable Care Act and the Small Business Jobs Act. CMS offers a guidance resource with details on the change.

    According to CMS, providers can start using the MBI as soon as their patients receive the new cards and should have systems in place to accept the new number by April 2018. The changeover includes a transition period from October 2018 through December 2019, during which time CMS will accept claims using either the HICN or MBI. Once the mailings begin in April, Medicare beneficiaries will be able to check on the status of their cards on Medicare.gov.

    CDC: Most Middle and High School Students Don't Get Enough Sleep

    More than 2 out of 3 high school-aged adolescents aren't getting enough sleep, and the situation seems to be getting worse, according to the US Centers for Disease Control and Prevention (CDC). The agency, which found a similar trend among middle school-aged children, warns that insufficient sleep can increase the risk for a host of health problems including obesity, diabetes, and injury.

    CDC's findings are based on results from the Youth Risk Behavior Surveys (YRBS) administered in 2015 to high school students in 30 states and 16 large urban school districts, and to middle school students in 9 states and 7 large urban districts. Students were asked to estimate how many hours of sleep they got on an "average school night," with researchers looking for the prevalence of responses that fell below American Academy of Sleep Medicine recommendations for at least 9-12 hours per 24 hours for children aged 6-12, and 8-10 hours per 24 for children aged 13-18. Here's what they found:

    • Among middle school students, 57.8% reported insufficient sleep, with nearly 12% reporting sleeping fewer than 6 hours a night.
    • Among high school students, 72.7% reported insufficient sleep, with about 20% reporting sleeping fewer than 6 hours a night.
    • In both groups studied, females fared worse than males, with 59.6% of middle school females and 75.6% of high school females reporting insufficient sleep, compared with 56% of middle school males and 69.9% of high school males.
    • The percentage of high school students who reported getting sufficient sleep dropped from 30.9% to 27.3% between 2009 and 2015 (2015 was the first year the YRBS was administered to middle school children).
    • Among states, Connecticut recorded the highest prevalence of high school students reporting insufficient sleep, at 80.1%. At the middle school level, the highest prevalence was recorded in Kentucky, at 64.7%.

    Solving the problem won't be easy, according to the CDC, which recommends that parents support good sleep health by maintaining consistent schedules with their children and imposing "media curfews" for a certain period of time before bed, or by not allowing the use of screen technologies in the child's room. Schools can also play a role by providing sleep education programs, says the CDC, but studies have shown that a 1-time program isn't enough—students tend to slip back into their old sleep habits unless the education is repeated periodically.

    Another possible help: delayed school start times, a change recommended by the American Academy of Pediatrics, the American Medical Association, and the American Academy of Sleep Medicine, according to the CDC.