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  • Getting a Handle on the Fee Schedule, Part 2: 4 Things to Know About the KX Modifier, MIPS, Dry Needling, and Revocation

    The final 2020 physician fee schedule rule released by the US Centers for Medicare and Medicaid Services (CMS) is generating lots of discussion among physical therapists (PTs), physical therapist assistants (PTAs), and other stakeholders for its potential future payment cuts and application of the PTA modifier, but there are other provisions in the rule that deserve attention too.

    Here are 4 things that you should know about the rule, set to go into effect on January 1, that might've been overshadowed by the headline-grabbing payment news. (For a more in-depth summary, check out APTA's regulatory review on the rule, and read part 1 of this PT in Motion News series, which covers the proposed cuts and PTA modifier)

    1. The Medicare payment threshold for outpatient therapy services will get a slight increase in 2020.
    The payment threshold system replaced the cap on therapy services under Medicare in 2018. As with the former therapy caps, the threshold amount is adjusted annually, and for 2020 the amount for the required addition of the KX modifier increases from $2,040 to $2,080 for physical therapy and speech-language pathology combined. (The occupational therapy threshold amount will be raised to $2,080 as well.) The threshold for targeted medical review will remain unchanged, at $3,000.

    2. Dry needling has codes—but that doesn't necessarily translate into payment.
    The final rule adds to the fee schedule 2 dry needling codes—one for needle insertions without injections in 1-2 muscles, and another for insertions in 3 or more muscles—but CMS has assigned a "noncovered" status to them, meaning that original (fee for service) Medicare won't pay for it. If you're working with any other insurance, including Medicare Advantage, check to see if they will pay for dry needling under the new codes. Also: Under Medicare fee for service, because these codes are "noncovered," an Advance Beneficiary Notice is not required, but it can be voluntarily provided (and is recommended).

    3. The Merit-based Incentive Payment System (MIPS) is getting tweaked, including its "opt in" offering.
    CMS is adjusting MIPS to include more measures such as diabetic foot and ankle care; falls screening and plan of care; elder maltreatment screen and follow-up plan; dementia: cognitive assessment, functional status assessment, and functional status change for patients with neck impairment; among others. The rule also removes 2 measures: pain assessment and follow-up, and functional status change for patients with general orthopedic impairments. The MIPS scoring system also will be changed, with the required final score to receive a neutral payment adjustment increasing to 45 in 2020, and then to 60 points for the 2021 payment year.

    The MIPS program will also continue to offer an "opt in" program for PTs meeting some but not all of the MIPS participation requirements. Details on how that system works are available through the CMS Quality Payment Program website. Questions about MIPS? Contact us at advocacy@apta.org.

    4. CMS will have wider authority to deny or revoke.
    The final rule grants CMS an expanded ability to deny or revoke a physician’s or other eligible professional's Medicare enrollment if the provider has been subject to action from a state oversight board, a federal or state health care program, an independent review organization, "or any other equivalent governmental body or program that oversees, regulates, or administers the provision of health care." The action must be related to unprofessional conduct that resulted in patient harm, and CMS allows itself leeway in issuing revocations or denials based on the nature of patient harm, the professional's conduct, and the number and types of disciplinary actions taken.

    Visit APTA's Physician Fee Schedule webpage for summaries, links to online learning opportunities, and resources documenting APTA's advocacy efforts. Also, join APTA regulatory experts for "The Changing Landscape of Federal Payment, Coverage, and Coding Policies," a live Q&A session set for December 10, 1:00 pm–2:00 pm ET. Download a prerecorded presentation and submit your questions in advance for a detailed discussion on a wide range of issues related to federal payment: the fee schedule, MIPS, TRICARE, and more.

    Comments

    • So who is fighting for dry needling to get paid?? Why are all the efforts backwards???? No CEU’s should be approved for dry needling until there are billing codes in Place and all the fee schedules Medicare and private insurances should have them in place. Also it should be an untimed code. Chiropractors are billing untimed codes for “Chiropractic acupuncture” While we are on cloud 9 supporting dry needling and fighting with the boards of acupuncture for non paid codes. Come on people wake up!!!

      Posted by Tom E on 11/27/2019 4:05 PM

    • Another slap in the face of physical therapists. A "non billable" CPT code for dry needling. We can only hope for a value sometimes in the future. I am so glad that I am in the twilight of my career.

      Posted by Charles Hollier on 11/30/2019 4:54 AM

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