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  • Proposed 2019 Fee Schedule: Goodbye Functional Limitation Reporting, Hello MIPS?

    It's official: the US Centers for Medicare and Medicaid Services (CMS) is proposing that physical therapist (PTs) join the list of providers who must participate in the CMS Quality Payment Program (QPP), which would mean that beginning in 2019 PTs providing services under Medicare Part B must participate in either the Merit-based Incentive Payment Program (MIPS) or an Advance Alternative Payment Model (APM).

    But that's not the only significant change proposed by CMS. In a win for APTA and its members, the proposed rule would also eliminate functional limitation reporting (FLR), a requirement consistently opposed by the association.

    APTA regulatory affairs staff are reviewing the proposed rule and will provide more detail in the coming weeks. Here are the major takeaways so far:

    MIPS-eligible clinicians would include PTs
    PTs, occupational therapists, clinical social workers, and clinical psychologists who furnish services under Medicare Part B would be added to the list of providers required to participate in the MIPS program or, alternatively, an approved APM as part of the QPP. Currently, PTs may voluntarily participate in the QPP; if the proposed rule is adopted, the program would begin for PTs in 2019.

    MIPS requires reporting in 4 performance categories—quality, promoting interoperability, clinical improvement activities, and cost. Providers earn points in each category, producing a total annual MIPS score, which in turn determines whether the providers earn a payment incentive, remain neutral in payment, or be subject to a penalty. Several of the data points must be reported electronically through certified EHR vendors or registries such as APTA’s Physical Therapy Outcomes Registry. The inclusion of PTs comes as MIPS enters its third year of the program.

    (Editor's note: check out this article from PT in Motion magazine to get the basics on MIPS)

    Goodbye FLR?
    The FLR requirement, long-characterized by APTA as an unnecessary burden on PTs and other providers, would be eliminated under the proposed rule. Change or elimination of the FLR requirement was an ongoing target for the association, which provided data to CMS showing that the requirement didn't accomplish the value-based care goals that CMS envisioned.

    Physical therapist assistant (PTA) differential officially established
    Under the proposed rule, CMS would establish 2 new therapy modifiers to identify the services furnished in whole or in part by PTAs or occupational therapy assistants (OTAs) beginning. January 1, 2020. The change, mandated by the Bipartisan Budget Act of 2018, establishes modifiers to be used whenever a PTA or OTA furnishes all or part of any covered outpatient therapy service, and would set the stage for a planned payment differential that would reimburse services provided by PTAs and OTAs at 85% of the fee schedule beginning in 2022. CMS anticipates the creation of a voluntary reporting system for the new modifiers beginning in 2019.

    Payment would get a slight increase
    After applying adjustment factors mandated by the Bipartisan Budget Act of 2018, the proposed fee schedule conversion factor would be increased slightly, from $35.99 to $36.05.

    KX modifier requirements remain
    The permanent fix to the Medicare therapy cap enacted in 2018 included requirements to continue using the KX modifiers for claims that exceeded a threshold, which in 2018, is $2,010 for PT and speech-language pathology (SLP) services combined. CMS also references the targeted medical review process, noting the threshold amount of $3,000. That system would continue, but the proposed rule emphasizes that not all claims exceeding the threshold would be subject to review.

    More alternatives to MIPS
    Providers who elect to participate in the QPP through APMs would be allowed a bit more leeway in the new rule. For example, providers participating in the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration project would avoid MIPS reporting and payment adjustments if they participate in Medicare Advantage arrangements that are "substantially similar" to APMs.

    "The proposed rule contains provisions that, while not unexpected, have some far-reaching implications for physical therapists," said Kara Gainer, APTA director of regulatory affairs. "APTA will be analyzing the proposed rule in more detail and providing more information as it becomes available."

    The association will also be providing comments on the proposed rule by the September 10 deadline.

    OB-GYN Group Embraces 'Fourth Trimester' Concept, Acknowledges Role of Physical Therapy in Postpartum Care

    A task force for the American College of Obstetricians and Gynecologists (ACOG) says it's time to frame postpartum care as an "ongoing process" requiring a personalized, cross-disciplinary approach—including the use of physical therapy when appropriate. APTA and its Section on Women's Health have registered strong support of the recommendations.

    In a committee opinion issued in May, ACOG's Presidential Task Force on Redefining the Postpartum Visit embraced the concept of the "fourth trimester," the idea that mother and child need ongoing care through at least the first 12 weeks after delivery. According to the task force, the fourth-trimester concept stands in contrast to the practice of an "arbitrary" single encounter with a primary care provider, often at 6 weeks after giving birth.

    Instead, the task force recommends contact with a maternal care provider within the first 3 weeks postpartum, during which the provider and patient would discuss a wide range of postpartum issues—from feelings of depression to the need for physical therapy to address incontinence and resumption of physical activity. Later, but within 12 weeks postpartum, a "comprehensive postpartum visit" should take place, according to the recommendations. That visit would also serve as a transition into ongoing well-woman care.

    The formal acknowledgement of physical therapy's role in postpartum care represents a significant conceptual shift, according to Carrie Pagliano, PT, DPT, president of the APTA Section on Women's Health.

    "Physical therapy has played a role in the postpartum health of women for many years; however, patient access to care was often limited to mothers who have a referring provider having prior experience with physical therapy, or it was simply left to the patient to find her own answers for her postpartum issues," Pagliano said. "Formal recognition of physical therapy in the fourth trimester not only recognizes our expertise in this area of care but provides a clearly stated standard of care for physicians providing postpartum care options for their patients."

    In a joint letter to ACOG on behalf the section and APTA, Pagliano and APTA President Sharon Dunn, PT, PhD, applauded the inclusion of physical therapists as a part of the health team envisioned in the recommendations.

    "Physical therapists' knowledge base and expertise related to the assessment and treatment of urinary and fecal incontinence, and for perinatal musculoskeletal issues including sexual dysfunction, pelvic girdle, and low back pain, as well as diastasis recti and painful scar tissue, will complement the contributions of other health care providers working in this important area of practice," the letter states. "Including physical therapy as a standard of postpartum care will increase the resources available for women to return to or improve their quality of life."

    For its part, the task force hopes the recommendations will influence payment and other policies around postpartum care, and will help to underscore the importance of fourth-trimester care among new mothers, among whom an estimated 40% never attend a single postpartum visit

    "The recognition of the fourth trimester is extremely important," Pagliano said. "Historically, women have talked about postpartum issues among themselves but may have been told 'that's just what happens when you have a baby.' These recommendations move the conversation into the light, providing a clear pathway, opening opportunities to discuss prevention, education, and treatment options for mothers following birth."

    APTA Input Included in Health Care Exec Group's Roadmap for Addressing Opioid Crisis

    In recommendations that at times echo those in a recently published APTA white paper, a new "roadmap" for addressing the opioid crisis adds to the voices calling for increased patient access to nonpharmacological and multidisciplinary approaches to pain management. APTA was among the organizations that helped guide development of the report.

    "A Roadmap for Action" is based on a summit sponsored by the Healthcare Leadership Council (HLC), a coalition of chief executives from hospitals, pharmaceutical companies, health insurers and other organizations. Summit participants, which included APTA, developed what HLC describes as "a concrete set of recommendations that identify best practices, prioritize solutions, and identify policy reforms necessary to collaboratively address the opioid crisis." APTA members may find the roadmap useful in advocacy and consumer education efforts.

    The roadmap focuses on 5 broad "priority areas" that require a range of actions at the legislative, regulatory, and industry level "to remove barriers to improved care, essential flow and use of data, and the development of therapeutic tools," according to the report. They are:

    • Improved system approaches to pain management
    • Improved system approaches to prevent opioid misuse
    • Expanded access to evidence-based substance-use disorder treatment and behavioral health services
    • Improved care coordination through data access and analytics
    • Development of sustainable payment systems that support coordination and quality care

    The list is followed by separate recommendations for "health care leaders," lawmakers, and regulators that are largely consistent with those developed by APTA in its white paper "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health Care." Both the HLC and APTA resources call for increased public and provider awareness of nonpharmacological options for pain management, increased payer support for nonopioid approaches, and wider use of multidisciplinary teams. The HLC roadmap includes physical therapists as providers whose expertise should be put to use "through recognition and payment of services, as well as integration into care teams and opioid stewardship models."

    "This document is a call to action, not only for lawmakers and regulators, but also for all sectors of American healthcare," the HLC report states. "While public policy has a vital role to play in removing barriers to advancements in care and empowering accelerated therapeutic innovation, private sector leadership is critical on every aspect of this issue, from improvements in pain management to data-driven proactive interventions to strengthened opioid stewardship."

    Proposed CMS Home Health Rule Includes Major Change to Payment System

    The US Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule for home health payment that resurrects elements of last year's proposal for an entirely new payment methodology by, among other changes, shifting care from 60-day to 30-day episodes and removing therapy service-use thresholds from case-mix parameters. And while the new proposal doesn't mimic last year's proposal in terms of across-the-board cuts, the practicalities of the payment system could have an impact on providers.

    On July 2, CMS unveiled the Patient Driven Groupings Model (PDGM) as part of its proposed 2019 home health prospective payment system (HH PP). If adopted, it would represent 1 of the most significant changes to home health payment in decades by moving to 30-day episodes of care and structuring payment around some 216 case-mix groups that don't include therapy visits as a factor. In a fact sheet on the proposal, CMS asserts that the new system, mandated by the Bipartisan Budget Act of 2018, would "move Medicare toward a more value-based payment system that puts the unique care needs of the patient first while also reducing the administrative burden associated with the HH PP." If adopted as proposed, the PDGM would take effect in 2020.

    APTA regulatory affairs staff will analyze the proposal in-depth over the coming weeks, but initial readings seem to indicate that much of the PDGM is a rehash of the Home Health Groupings Model (HHGM) that CMS proposed last year. That proposal met with stiff resistance from many patient and provider organizations including APTA and the association's Home Health Section, with APTA describing the HHGM as a system with "significant flaws" that "will have a harsh and dramatic effect on patient care."

    Ultimately, CMS backed off from adopting the system in 2017, promising a retooled proposal in 2018. In the intervening months, the agency convened a technical expert panel to review the issue. That panel included APTA member Bud Langham, PT, MBA, with APTA Director of Regulatory Affairs Kara Gainer attending as an observer.

    The proposed PDGM has at least 1 significant change from the HHGM: because it's designed to be implemented in a budget-neutral way, it doesn't include the same $950 million in cuts associated with the 2017 proposal.

    But that doesn't mean providers are out of the woods, according to Gainer.

    “While the budget neutrality will prevent massive across-the-board cuts, CMS notes that the impact on payments as a result of the proposed PDGM will vary by specific types of providers and location," Gainer said. "Some individual home health agencies may experience different impacts on payments due to a variety of factors, most notably the ratio of overall visits that were provided as therapy versus skilled nursing.”

    Essentially, the PDGM classifies 30-day episodes according to a combination of factors related to 5 major buckets. They are:

    Timing—"early" vs "late." Only the first 30-day episode would qualify as "early"—all other episodes would be considered "late."

    Admission source—"community" vs "institutional." A 30-day period would be classified as "institutional" if the patient had an acute or postacute facility stay within 14 days of the start of the episode—if not, the admission source would be labeled "community."

    Clinical group. Based on principal diagnoses, patients would be assigned to 1 of 6 clinical groups: musculoskeletal rehabilitation; neuro/stroke rehabilitation; wounds (both surgical and nonsurgical); behavioral health care (including substance use disorder); complex nursing; and medication management, teaching, and assessment.

    Function level—"low impairment," "medium impairment," or "high impairment." CMS would rely on Outcome and Assessment Information Sets (OASIS) codes to designate a patient's level of function.

    Comorbidity adjustments—"no adjustment," "low," or "high." A single secondary diagnosis that falls within a list of 11 comorbidity subgroups could qualify the patient for a low-comorbidity adjustment; 2 or more that results in comorbidity subgroups interacting could result in an adjustment for high comorbidity.

    The combination of categories are what comprises the 216 PDGM payment groupings. Those groupings would define payment for the 30-day episode and could in turn receive further adjustments if fewer than 2 to 6 visits are furnished during the 30-day episode, depending on the PDGM group.

    The proposed rule also includes changes to certifying and recertifying patient eligibility for continued home health care; an allowance for home health agencies to report the cost of remote patient monitoring; and a transition toward payment for home infusion therapy. The changes proposed by CMS would result in an estimated 2.1% increase in payments in 2019, or about $400 million.

    APTA staff will continue to review the proposal and develop a fact sheet in the coming weeks. The association will prepare comments on the proposal for submission before the August 31 deadline. APTA also will create a template letter that members can use to provide their own comments to CMS.

    CMS Seeking Comments on Self-Referral Prohibitions in Stark Law

    In its ongoing efforts to decrease regulatory burdens, the US Centers for Medicare and Medicaid Services (CMS) has turned its attention to a law that, with the exception of physical therapy and a few other treatments and procedures, bars physicians from referring patients to services in which the physician has a financial interest. The CMS call for feedback—an effort largely focused on how the law might be loosened up—comes at a time when APTA and other organizations are voicing support for a bill that would do nearly the opposite by eliminating the exemptions allowing for self-referral for physical therapy and other services.

    The CMS Request for Information (RFI) is part of an initiative dubbed the "Regulatory Sprint to Coordinated Care." According to CMS, the focus of the initiative is on "identifying regulatory requirements or prohibitions that may act as barriers to coordinated care, assessing whether those regulatory provisions are unnecessary obstacles to coordinated care, and issuing guidance or revising regulations to address such obstacles and, as appropriate, encouraging and incentivizing coordinated care."

    According to the RFI, CMS is setting its sights on the Stark Law because of its potential to bump up against new models of care delivery by seemingly prohibiting systems that could be interpreted as forms of self-referral.

    "CMS is aware of the effect the physician self-referral law may have on parties participating or considering participation in integrated delivery models, alternative payment models, and arrangements to incent improvements in outcomes and reductions in cost," CMS states. "We are particularly interested in your thoughts on issues that include, but are not limited to, the structure of arrangements between parties that participate in alternative payment models or other novel financial arrangements, the need for revisions or additions to exceptions to the physician self-referral law, and terminology related to alternative payment models and the physician self-referral law."

    The RFI includes 20 questions soliciting ideas on topics ranging from what additional exceptions to the Stark Law might be considered to how CMS could track physician overuse of self-referral. APTA is reviewing the RFI, and will collaborate with the APTA Private Practice Section and other stakeholders to provide comments by the August 24 deadline. The association also provides a template letter for individuals to submit comments directly to CMS via its regulatory issues webpage (scroll down to second bullet under "APTA's Current Regulatory Advocacy Efforts").

    The general aim of the RFI would seem to run counter to APTA's own efforts to toughen up the rules against self-referral. Last year, the association joined fellow members of the Alliance for Integrity in Medicare in support of a bill in the US House of Representatives that seeks to eliminate self-referral exemptions for so-called "in-office ancillary services"—physical therapy, anatomic pathology, advanced imaging, and radiation oncology. The idea of eliminating the loopholes is also supported by AARP. To date, the legislation has not been scheduled for House committee review.

    "APTA supports efforts to ease the regulatory and administrative burdens faced by health care providers, but those efforts need to be weighed against possible effects on patient choice and access to care," said Justin Elliott, APTA's vice president of government affairs. "Our response to this RFI will take great care to help CMS understand the possible unintended consequences of creating more ways around self-referral without other safeguards in place."

    Want more information on the Stark Law and the IOAS exceptions issue? Visit APTA's legislative issues webpage on self-referral.

    CMS to Expand List of DMEPOS Requiring Prior Authorization

    Physical therapists (PTs) who are providers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) take note: the US Centers for Medicare and Medicaid Services (CMS) is adding 31 codes to its list of devices that require prior authorization under Medicare. The additional codes will go into effect on September 1 of this year.

    The codes, all related to power wheelchairs, already were subject to prior authorization in 18 states as part of a demonstration project aimed at reducing improper payment. With that demonstration project set to end on August 31, CMS decided to expand the requirements to all states and fold the list into its broader DMEPOS demonstration project launched in 2015.

    CMS offers a webpage focused on the DMEPOS prior authorization program and has published a notice and list of the 31 codes to be added. A full list of DMEPOS requiring prior authorization (minus the 31 codes to be added in September) is also available from CMS. APTA offers more resources at its DMEPOS webpage as well as through a clinical mobility device documentation guide.

    CMS Reports High Levels of Participation in MIPS; Will It Be Expanded to PTs in 2019?

    Things are looking good for the Merit-Based Incentive Payment System (MIPS), according to the US Centers for Medicare and Medicaid Services (CMS). According to CMS, participation in MIPS—which could be required of physical therapists (PTs) as early as next year—was just above 90% during its first year of operation.

    The 91% clinician participation rate was slightly better than the CMS goal of 90%, and included particularly strong performance from accountable care organizations and physicians in rural areas, which reported at rates of 98% and 94%, respectively, according to a blog post from CMS administrator Seema Verma. Beginning in 2019, clinicians can earn Medicare payment increases or face penalties based on quality reporting data provided through the program.

    MIPS is part of a broader effort by CMS to shift toward value-based payment systems through the Quality Payment Program (QPP). Under QPP, providers can choose 1 of 2 paths: reporting through MIPS, or participating in an Advanced Alternative Payment Model (AAPM). MIPS requires reporting in 4 performance categories—quality, promoting interoperability, clinical improvement activities, and cost. Providers earn points in each category, producing a total annual MIPS score, which in turn determines whether the providers earn a payment incentive, remain neutral in payment, or be subject to a penalty. Several of the data points must be reported electronically through certified EHR vendors or registries like APTA’s Physical Therapy Outcomes Registry.

    Although PTs are not yet required to report outcomes through MIPS, they can participate voluntarily—an option strongly encouraged by APTA, given that all indications point to PTs being required to participate in MIPS or APMs as early as 2019. CMS is expected to make its decision on the inclusion of PTs in MIPS in early July 2018.

    According to Verma, while CMS presses for broader participation in MIPS, it will remain "committed to removing more of the regulatory burdens that get in the way of doctors and other clinicians spending time with their patients" through its "Patients Over Paperwork" initiative.

    "We’re also eager to improve the clinician and patient experience through our Meaningful Measures initiative so that clinicians can spend more time providing care to their patients and improving the quality of care their patients receive," Verma writes. "Within MIPS, we are adopting measures that improve patient outcomes and promote high-quality care, instead of focusing on processes."

    Get ready for the future of PT payment: APTA offers a wide range of online resources on value-based care in general and MIPS in particular, including a readiness self-assessment quiz, a podcast series, a video, a frequently-asked question page on MIPS, and more. Additionally, APTA's Physical Therapy Outcomes Registry has earned "qualified clinical data registry" status from CMS, meaning that PTs who participate in MIPS can use the PTOR to submit their data to CMS.

    AMA: Drop in Opioid Prescription Rates Good News; More Nonopioid Pain Treatment Needed

    The American Medical Association (AMA) is applauding new data showing that opioid prescriptions fell dramatically in 2017—and using the news as an opportunity to promote access to "affordable, non-opioid pain care."

    In its report, AMA cites statistics from IQVIA Institute for Human Data Science, which found that opioid prescription rates fell by 10% in 2017, the steepest drop in 25 years. All 50 states reported decreases in prescriptions of 5% or more. Additionally, the report states that physicians are increasing their use of prescriptions drug monitoring programs and expanding their treatment capacity through certifications to administer in-office buprenorphine, a drug used in the treatment of opioid use disorder.

    That's all good news, the AMA report says, but more needs to be done, both in terms of the nation's addiction treatment efforts and the health care system's overreliance on opioids in the treatment of pain. Among AMA recommendations: a call for "all public and private payers… [to] ensure that patients have access to affordable, non-opioid pain care."

    “While this progress report shows physician leadership and action to help reverse the epidemic, such progress is tempered by the fact that every day, more than 115 people in the United States die from an opioid-related overdose,” said Patrice A. Harris, MD, MA, chair of the AMA Opioid Task Force in an AMA news release. “What is needed now is a concerted effort to greatly expand access to high-quality care for pain and for substance use disorders. Unless and until we do that, this epidemic will not end.”

    APTA has made the opioid crisis a priority in its public education and advocacy efforts through the #ChoosePT opioid awareness campaign and participation in multiple multiorganization initiatives, including a National Quality Partners "Opioid Playbook" that offers actions that can be taken to shift health care away from the overuse of opioids for treatment of noncancer pain. Earlier this year, APTA hosted a live Facebook-broadcast panel discussion titled "Beyond Opioids: Transforming Pain Management to Improve Health."

    CMS Hopes to Reboot 'Pre-Claim Demonstration' Proposal for HHAs in 5 States

    The US Centers for Medicare and Medicaid Services (CMS) plans to revive a home health agency (HHA) "pre-claim demonstration" project it shelved in 2017 due in part to criticism that the program created significant administrative burdens and reduced access to care. The reconstituted project will be implemented in 5 states and is described as "optional," though HHAs that choose not to participate would face a 25% cut in payments.

    The demonstration project will be carried out in Florida, Illinois, North Carolina, Ohio, and Texas, and would offer HHAs 3 paths in seeking payment for Medicare beneficiaries: submit documentation for 100% of Medicare patients while they are receiving care (a "preclaim review"), submit 100% of all claims for a postpayment review, or opt out entirely and swallow a 25% payment cut with the possibility of review by a recovery audit contractor. The previous version of the project included only the preclaim review provisions; according to a statement from CMS administrator Seema Verma, the new plan "offers new flexibility and choice for providers."

    CMS' earlier attempt at the project was implemented in Illinois but was suspended after some HHAs were forced to close their doors, pointing to the program's administrative burdens as part of the cause. Federal lawmakers requested that the program be shut down until a better plan could be developed.

    Like its earlier version, the project is aimed at reducing what CMS has identified as high rates of Medicare fraud among HHAs. CMS stated that although it will limit the project to 5 states initially, it may consider expanding the project to other states in the Palmetto/JM jurisdiction—mainly southern states as well as New Mexico, Indiana, and Kentucky. CMS has not yet set a start date for the program.

    APTA will provide comments to CMS within the 60-day window triggered by publication of the proposal in the Federal Register, and will share information on how individuals can provide comments at the APTA federal advocacy webpage.

    Major Overhaul of VA Choice Could be On the Way—But Health Net Won't Be Around For It

    Some big changes may be in store for Veterans Affairs (VA) patients and providers, as Congress moves toward approval of an expansion of care options for VA patients and the VA announces that it's ending a relationship with Health Net Federal, a major contractor for the VA Choice program.

    The most far-reaching decision is the advancement of a bill named the VA Mission Act. That bill, already approved in the US House of Representatives and likely to pass in the US Senate, would commit $52 billion to the creation of a new program that would overhaul VA Choice, the program created in 2014 to increase access and reduce wait times for VA patients by allowing greater use of non-VA providers.

    The VA Choice program faced criticism that it has fallen short of its aims, and is set to run out of money in late May or early June 2018. If signed into law, the Mission Act would provide funding while the program is retooled. The Trump administration has already indicated support for the legislation.

    Once up and running, the new program would allow veterans to access private sector care in instances in which long travel times, long wait times, or a VA facility's poor service prevent the patient from receiving adequate care. The program would also allow up to 2 walk-in visits per year at non-VA clinics, according to a report in the Military Times.

    In another move related to VA Choice, VA announced that it will be allowing its contract with Health Net Federal to expire on September 30, 2018. The company is the contractor for VA Choice services in regions that include all or portions of 37 states

    VA has not announced a new contractor for the regions now served by Health Net, nor has it provided any guidance on what providers currently contracted with Health Net should be doing to prepare for the change. For its part, Health Net issued a statement that it will "remain focused on program performance improvements" and "will continue to work collaboratively with VA to ensure providers receive prompt and timely payments during this period of transition." The company stated that it will provide updates on the transition on its Veterans Affairs webpage.

    ATPA regulatory affairs staff will continue to monitor the progress of the legislation and transition from Health Net, and will share updates through PT in Motion News and other resources.