Between 4 proposed new physical therapy codes, potential expansion of the Comprehensive Care for Joint Replacement (CJR) model, Tricare contracts, final rules for skilled nursing and inpatient rehab facilities (SNFs and IRFs), and provisions in the proposed outpatient prospective payment system 2017 rule, APTA staff covered plenty of ground as they answered member questions during the 30-minute Insider Intel phone-in session August 17.
A full recording of the August 17 call is available here. Below are some highlights from the call and links to related online resources for more information.
- The Centers for Medicare and Medicaid Services (CMS) announced 3 new physical therapy evaluation CPT codes and 1 reevaluation code in the 2017 proposed physician fee schedule. These codes will replace the current single evaluation code, 97001, and reevaluation code, 97002, which will be removed from the American Medical Association's CPT manual for 2017. This means PTs will not be able to use 97001 or 97002 any longer.
- Although the 3 evaluation codes are tiered to represent different levels of patient complexity, CMS gave them all the same value-the same value as the current 97001 code. APTA, through the AMA submission process for new CPT codes, recommended different payment values to correspond with the complexity levels, but CMS chose not to follow the recommendation for 2017.
- Because the 97001 and 97002 CPT codes will no longer exist, the proposed new codes will be adopted across the health care spectrum-by private payers as well as Medicare. Medicare will pay based on the values published in the physician fee schedule, but private payers may determine their own values, and PTs will need to confirm those values with their payers.
- One reminder for the proposed codes, and the fee schedule overall, is that the rule is still a proposal, and the final rule won't be released until late October or November. APTA will submit comments on behalf of the profession reiterating our recommendation for tiered values, among other things. For more, see this Proposed Physician Fee Schedule: New Evaluation Codes, Same Payment (July 8, 2016) and the Medicare Physician Fee Schedule page.
- CMS's proposed bundled payment pilot for hip and femur fracture will cover the same metropolitan statistical areas (MSAs) as the current CJR THA and TKA pilot. A link to the CJR MSAs, and even to a list of the individual hospitals, are available from APTA's CJR webpage. The new cardiac care bundled payment pilot, announced at the same time and covering heart attacks and bypass surgery, will be mandatory in 98 metropolitan statistical areas (MSAs), which are listed in the proposed rule but won't be definitive until a final rule is released later this year. In the meantime, APTA will provide comments on the proposal. For more, see CMS Expands Mandatory Bundling Program to Cardiac Care, Including Rehab (July 26, 2016) and CMS.gov's related fact sheet.
- The Department of Defense has redrawn coverage regions under its Tricare health insurance program, now using Humana Military for the eastern region and Health Net Federal for the west. APTA has heard from some members that Humana is reducing payment amounts for physical therapist services. If any members are experiencing this, they're encouraged to contact the association at firstname.lastname@example.org so staff can provide examples during discussions with Humana. For more, see Defense Department Makes Big Change in Tricare Vendors (July 27, 2016).
- Under the proposed outpatient prospective payment system (OPPS) rule released in July, a new classification was added to the comprehensive ambulatory payment classifications (CAPCs), which will reimburse providers a single payment for comprehensive observation services in outpatient facilities, including clinic visits, all types of emergency department visits, and critical care visits. The ruling also reinforces that certain outpatient services similar to therapy will be payable under the CAPC, but it isn't clear what will distinguish therapy vs nontherapy services. Again, as this is a proposal and not a final rule, APTA will submit comments asking for clarity, among other things. Meanwhile, any PTs who receive payment denials from CMS related to the CAPC, or who have questions about it, are encouraged to contact APTA at email@example.com.
Visit the Insider Intel webpage to look for opportunities to participate in future calls.