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  • Proposed Fee Schedule Rule Wrestles With PTA, OTA Services Delivered 'In Part'; Includes Changes to MIPS

    Despite serious questions and criticisms from APTA, the American Occupational Therapy Association (AOTA), and other stakeholders, the US Centers for Medicare and Medicaid Services (CMS) intends to move ahead with its plans to require providers to navigate a complex system intended to identify when therapy services are furnished by a physical therapist assistant (PTA) or occupational therapy assistant (OTA). The approach, which in 2022 would trigger a payment differential depending on how many minutes of services are provided by a PTA or OTA, is included in the proposed 2020 physician fee schedule rule released by CMS on July 29.

    As always, the physician fee schedule (PFS) rule is an extensive document that covers a wide range of providers and settings, with an emphasis on individual provider payment rates. But for the physical therapy profession, the big story for the 2020 proposed rule is related to how CMS plans to require providers to comply with a law requiring identification of services furnished "in whole or in part" by a PTA or OTA. The approach being contemplated by CMS—to set a "de minimis" 10% bar—has been criticized by APTA as one that has "serious implications for beneficiary access to care," particularly in rural and underserved areas.

    The proposed 2020 rule would require the new PTA and OTA modifiers (CQ and CO, respectively) to be included in claims beginning January 1, 2020, with a payment differential implemented in 2022. CMS also proposes to add a requirement that the treatment notes explain, by way of a short phrase or statement, why the modifier was or wasn't used for each service furnished that day. In short, the system is rooted in minutes of service, and would require the use of the applicable modifier that would indicate when a PTA or OTA provided outpatient therapy services for 10% or more of the total time spent furnishing the service.

    And yet, as most physical therapists (PTs) and occupational therapists (OTs) well understand, the provision of therapy services isn't quite that simple. Questions start to pile up fairly quickly: what if the PTA or OTA services are provided concurrently with the PT or OT? What if the PTA or OTA services are administrative or nontherapeutic? What about group therapy? How is time designated when delivering supervised modalities?

    CMS attempts to anticipate these and other potential complications by making a few definitive decisions—for instance, administrative or nontherapeutic services provided by a PTA or OTA that could be provided by others without PTA or OTA education and training don't count—and providing examples of how the time allotments would be calculated in various scenarios.

    Despite the extensive requirements and explanations (and accompanying charts), a CMS fact sheet on the proposed fee schedule states that the system imposes "the minimum amount of burden for those who bill for therapy services while meeting the requirements of the statute."

    APTA disagrees with that assertion, and has voiced additional concerns about how the system would impact patient access to care. While acknowledging that CMS is bound by law to create a PTA modifier, the association takes issue with CMS’ interpretation of “in part,” and asserts that the agency's attempt to quantify what "in part" means is excessively complex, discounts the role of the therapist, and exceeds the intent of the law. That mischaracterization of the law, APTA argues, will quickly lead to confusion and loss of access to care, particularly among beneficiaries in and underserved rural areas.

    APTA plans on continuing its advocacy for a less complex, more patient-friendly system, including lobbying federal legislators to take a closer look at the plan and seeking meetings with CMS. APTA also will provide comments on the PTA/OTA modifier plan and other elements of the proposed fee schedule by the September 27, 2019, deadline, and will create a customizable template letter, available on APTA's Regulatory Action webpage, for individual provider comment.

    Here are other highlights of the proposed rule:

    Payment would increase slightly
    CMS estimates that the 2020 conversion factor would be $36.0896, just about a nickel more than 2019's $36.04.

    MIPS measures and performance thresholds for PTs and OTs would change—and CMS is looking at ways to make things less complex
    The proposed rule would add measures for diabetes mellitus neurological evaluation, diabetes mellitus evaluation of footwear, screening for depression and follow-up plan, falls risk assessment, falls plan of care, elder maltreatment screen and follow-up plan, tobacco use screening and cessation intervention, dementia cognitive assessment, falls screening for future falls risk, and functional status change for patients with neck impairments. The rule also removes 2 measures: pain assessment and follow-up, and functional status change for patients with general orthopedic impairments.

    Additionally, CMS has proposed that MIPS-eligible clinicians with a final score of 45 would receive a neutral payment adjustment, a change that CMS believes will lead to more clinicians receiving positive adjustments than negative ones. The current neutral payment adjustment score is set at 30.

    CMS is also proposing the concept of shifting to a streamlined version of MIPS, which it has dubbed "MIPS Value Pathways," (MVPs) for 2021 and beyond. According to CMS, the MVP system would help providers align activities across the 4 existing MIPS categories by specialties or conditions. MVPs would focus on population health priorities and reduce reporting burden by limiting the number of required specialty- or condition-specific measures so that all clinicians or groups reporting on a clinical area would report the same set or sets of measures. The change would also provide more data and feedback to clinicians, which in turn "helps clinicians quickly identify strengths in performance as well as opportunities for continuous improvement," according to a CMS press release on the proposed rule.

    It's not a "limitation," it's a "threshold amount"
    In a change that adds semantic reinforcement to the end of a hard cap on therapy services established in 2018, the proposed rule clarifies that the dollar amounts assigned to therapy services aren't limitations per se, but "threshold amounts" that, when exceeded, require the KX modifier. In turn, the KX modifier would be regarded as confirmation that the additional services are medically necessary. CMS also says it will clarify regulations on the medical review threshold and the applicable years for the targeted medical review process

    New dry needling codes, and changes to codes and RVUs for biofeedback
    The American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel approved 2 new CPT codes to report dry needling of musculature trigger points in 2020. These codes, with proposed relative value unites (RVUs) of .32 (205X1, needle insertion without injection, 1 or 2 muscles) and .48 (205X2, needle insertion without injection, 3 or more muscles), were surveyed and reviewed by the Health Care Professions Advisory Committee, a group of non-MD/DO health professionals, including a PT representative. Those new codes are included in the proposed PFS.

    Also, in September 2018, the AMA CPT Editorial Panel replaced CPT code 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) with 2 new codes to describe biofeedback training initial 15 minutes of 1-on-1 patient contact and each additional 15 minutes of biofeedback training.

    As a follow-up to another CPT editorial panel decision in 2018 that replaced a single CPT biofeedback code with 2 separate codes, CMS is also proposing an RVU of 0.90 for CPT code 908XX (biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry when performed; initial 15 minutes of one-on-one patient contact) and 0.50 for code 909XX (biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry when performed; each additional 15 minutes of one-on-one patient contact). The proposed rule also designates the 2 codes as “sometimes therapy” procedures, meaning that an appropriate therapy modifier is always required when this service is furnished.

    Intensive cardiac rehab (ICR) would be expanded
    CMS is proposing that coverage for ICR, which tends to be more structured, rigorous, and integrative in its emphasis on diet and cognitive-behavioral factors, be expanded to beneficiaries with stable chronic heart failure. It's also looking to expand coverage for both ICR and cardiac rehabilitation to other cardiac conditions as identified through a national coverage determination—providing that determination finds clinical support for an expansion.

    CMS is looking for comments on bundled payments
    Can concepts and principles associated with bundled payment models—particularly the idea of per-beneficiary payments for multiple services or condition-specific episodes of care—be applied to the PFS? CMS believes it has the flexibility to implement bundling concepts in future rules, and is looking for public comment on the idea.

    Want to hear more about the proposed fee schedule directly from the APTA experts? Be on the lookout for an upcoming special "Insider Intel" phone-in session exclusively devoted to the PFS in the coming weeks. We'll announce the date and time via PT in Motion News and social media.


    • I am so very glad I retired from this bureaucratic nonsense. Neutral pay adjustments, negative pay adjustments, positive pay adjustments. Sit, beg, rollover. Pavlov's dog will have nothing on us.

      Posted by Brian Miller on 8/1/2019 12:02 AM

    • I'm concerned about the decreased reimbursement for PTA treatments. CMS has argued that this decrease in reimbursement is the same that was implimented for nurse practitioners and physician assistants. However, the stark difference is that those two professions don't have to be directly supervised. PTAs cannot function without a PT being on site and in direct line of vision, in outpatient facilities. This is not one in the same. Not to mention PTAs can function under supervision in all other settings. I have yet to see the APTA step up to protect PTAs in outpatient settings, as well as the private practices. A policy like this can potentially cause businesses to start closing their doors.

      Posted by Elizabeth Powell on 8/1/2019 10:37 AM

    • To think that after 10 years of practicing my PTA status will now change reimbursement rates is appalling. CMS and their ridiculous changes will lead to continued refusal benefits by more providers due to these unclear and unjust rules.

      Posted by Carlos E Lopez on 8/1/2019 10:37 AM

    • I am too glad I am no longer practicing as the art has turned into a business machine. I loved working with patients but this payment system is far toooo complicated for me and many other therapists especially for PTAs. Please keep fighting for a simple, sensible charging system... Cash might be better!!!!

      Posted by Vanie L Jones on 8/1/2019 1:13 PM

    • MD s have PAs , PTs and OTs have PTAs/COTAs Our skills should not be questioned & should not be minimized when studies show our interventions are decreasing costs by the billions. We are taught by PTs & supervised by PTs . The more cuts made to PT/OT and the sicker they are sending people home ( to decrease hospital stays due to cuts in reimbursement ) will increase exponentially, our already skyrocketing healthcare costs. With the country aging , therapy services will be even more of a vital component of decreasing hospital stays, ER visits, return trips to the hospital/ER. We are already overburdened by unnecessary paperwork/justification of our highly skilled care just so reviewers can find ONE little mistake in the documentation. So that they can justify not paying FOR WHOLE EPISODES! The transition to online medical records have forced PCP from private practice, driving them to huge conglomerate healthcare system. Health care as a whole is suffering from the electronic medical records system, the patients report it , the staff report it. And yet THEY CONTINUE to question our services and our justification for services. When will they be satisfied? Who is reviewing them and their mistakes and their decisions and judgement??

      Posted by emily evans on 8/3/2019 2:18 PM

    • I understand where commentators feel frustrated and I hope feel motivated to help with advocacy but when I see comments such as " I have yet to see the APTA step up to protect PTAs in outpatient settings, as well as the private practices" such as above (Elizabeth Powell) I have to wonder if the commentor is either not reading what the article states (" Despite serious questions and criticisms from APTA, the American Occupational Therapy Association (AOTA), and other stakeholders, the US Centers for Medicare and Medicaid Services (CMS) intends to move ahead...") or you simply don't believe it? Regardless, I hope all will view this as we are in this together and take that perspective and join in advocacy efforts such as submitting comments utilizing APTA template letters and more.

      Posted by Matthew Mesibov -> =FPc? on 8/3/2019 3:47 PM

    • It is astonishing to me the lack of information that was available to us when MIPS went live 1/1/19. I mean, webinars were coming out all through the first quarter because no one knew what was going on. My personal definition of hell is a place where no one will tell you how to do it right, but you get penalized for doing it wrong. Increasingly, CMS keeps showing us its true origins.

      Posted by Jason Wilwert on 8/3/2019 11:51 PM

    • Elizabeth, I don't know where you live, but here in AZ, and in many other states, an OP PTA does not have to supervised on-site by a PT. I am a PTA in AZ and our laws state that you must be supervised on-site for your first 2,000 hours in the field. After that, you can be offsite supervised.

      Posted by Jen on 8/6/2019 7:31 PM

    • Cash pay PT!

      Posted by Tim RICHARDSON on 8/7/2019 8:34 PM

    • This MIPS stuff is too complicated. I am advising people not to go into PT.

      Posted by Linnea Comstock -> AGXa< on 8/15/2019 9:55 AM

    • This is fabulous news! We're getting a raise from CMS! But wait!. The increase amounts to 0.14%? Let's do a little arithmetic here. The CPI, one of the most accepted government measures of inflation, was 1.8% for the most recent quarter. That means our "raise" is approximately 13 times LOWER than the rate of inflation. And the CPI is well known to greatly under pace true inflation, which is considerably higher than the CPI. So, in other words, in real dollar terms, we received a PAY CUT!!!. So what else is new? The problem is, we have absolutely no leverage to bargain for higher pay and lesser bureaucratic burdens. If we refuse to provide PT to Medicare patients, the government saves money. So where is their incentive to change? There isn't one. Therefore, they won't change. They'll keep doing the same thing. As a consequence, we will continue to experience further degradation in our reimbursement and further escalation of our bureaucratic burdens. They can say one thing but since when has government told the truth. One of my maxims in understanding government is that lying is much more common than truth telling. In truth, the only way to win at this game is not to play it. https://www.youtube.com/watch?v=NHWjlCaIrQo

      Posted by Brian Miller on 8/24/2019 11:19 PM

    • Bring focus back to patient-centered care. APTA...were is the advocacy for cash-based PT and allowing Medicare patients to contract directly with there PT provider?

      Posted by Catherine Mormile on 8/28/2019 3:13 PM

    • Definitely disappointing that inflation continues to outpace our payment adjustments. I hope this improves and expect the APTA the continue their lobbying efforts to this effect. It’s truly having a very negative impact on practice. That said, I understand the APTA isn’t omnipotent. We can’t unilaterally change CMS policy. We’re truly better together, and greater membership will increase our power and ability to invoke change.

      Posted by Seth Peterson on 8/30/2019 10:34 PM

    • It is not the first time when US Rehab will be affected in the middle of the 80's and beginning of 90's they almost destroyed it. So prepare for hard times... ABN notice is a clue w/ Cash Tx and let the pt's deal w/ own insurance. APTA haven't supported US enough.....

      Posted by Krzysiek on 8/31/2019 2:29 AM

    • Will the new dry needling codes (205X1 and 205X2) be considered timed based or service based codes? If timed based then this is low reimbursement. If service based then it can be bundled with e-stim and get semi-decent reimbursement. Right?

      Posted by Matt K on 8/31/2019 12:44 PM

    • I own and operate an OP facility in CA w/3 PTs and 2 PTAs. We have mostly 1 hour Evals, 30 min. sessions for PVT PT and 45 min. sessions for MC w/the licensed staff. This is so that we, the providers can still have time to think, treat and document w/quality. We make no profit!! The only reason we can afford to do this is our CASH services: fitness training and massage. I know we should be cutting our treatment times to 15-20min, but that would be 1 billable code ie. $35 or bill the other 3-4 codes when an aide sees them and risk injury, poor outcomes, negligence and ultimately our license when malpractice ensues. WE are all "between a rock and a hard place." risk our license, quality of care and quality of life or close our doors? I've been contemplating this for years. I'm perplexed by the purpose in payment change to this MIPS program?? Isn't common sense -KISS? Rob Peter to pay Paul. But, who's looking? Who's regulating the "true" reporting? Last time I was in Sacramento fighting for CPTA against POPS, congress actually stated to us in the court room, that the law would stay as is, no POPS; however, CPTA could NOT enforce the law. Interesting how laws can not be enforced when it's in our favor. Open 19 years now and have had nothing but pay cuts. My request to APTA is to push for standard rates of reimbursement for nothing less than 30min. of treatment w/the licensed staff ie. $100/30 min. Keep durations to 8, 12 and 16 visits lumping diagnoses in those three categories and requiring auth and note review for any requests beyond that. this is simple. Thank you for the work thus far, but again, in 19 years, not much has gone our way nor made sense.

      Posted by Lissa Trevino on 8/31/2019 1:55 PM

    • Where the heck is the advocacy and protection our dues are supposed to pay for. More bad news from an association that protects itself and leaves us all flapping in the wind. WTF!!

      Posted by Brian on 8/31/2019 4:59 PM

    • Did anybody notice the dry needling codes reimburse about the same as e-stim?!? I think there's a little more skill involved and research supporting dry needling. With that being said, are these new codes timed or untimed?!?

      Posted by Matt Kud on 8/31/2019 11:53 PM

    • @Matt: These are untimed codes. CMS has not put forth coverage or billing requirements for these codes in this rule, but is seeking feedback on whether these codes should be considered “always therapy” or “sometimes therapy codes.”

      Posted by APTA Staff on 9/3/2019 6:50 AM

    • Will the new modifiers be needed in patients with Medicare as a secondary insurance?

      Posted by Will Brasky on 9/4/2019 2:46 PM

    • @Will: The modifiers will need to be affixed to claims submitted to Medicare for reimbursement under the Physician Fee Schedule.

      Posted by APTA Staff on 9/5/2019 7:32 AM

    • @APTA Thanks for clarifying that it's an untimed code. Since it's untimed would that mean that CPT code 97014 could also be billed concurrently with it?

      Posted by Matt Kud on 9/10/2019 12:55 PM

    • @Matt: It may be appropriate to bill both the needling code and the estim code. As with any procedure it would be at the discretion of the therapist to bill the most appropriate code(s) based on the intent of the procedure. Payer policy regarding the use of these codes may also influence whether the two codes can be billed together.

      Posted by APTA Staff on 9/11/2019 8:12 AM

    • I have been a PTA for almost 30 years and have never had to worry about my job. Now I worry they will not hire or start firing us because of the new rules. I know some PTs that will not even think about hiring PTA’s. I love what I do but it seems like we do more paperwork and less patient care. I’m not sure how much more documentation and justification I can take. It’s always something. Let us do our job and let us care for the patients we care for so much.

      Posted by Dori on 12/31/2019 9:16 PM

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