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  • Humana Adopts PTA Coding System, Anticipates Payment Differential Beginning in 2022

    Commercial health insurance giant Humana has announced that it's falling in line with rules from the Centers for Medicare and Medicaid Services designed to establish an 85% payment differential for therapy services delivered "in whole or in part" by a PTA or occupational therapy assistant. Consistent with CMS, Humana is requiring use of code modifiers in 2020, with no changes to payment until 2022.

    The new system, which establishes a code modifier ("CQ" for PTAs and "CO" for OTAs) began on January 1 for Medicare Part B payments. The new approach was triggered by federal law that mandated the creation of a way to denote the volume of physical therapy and occupational therapy services delivered by PTAs or OTAs, and then create a payment differential for those services. In its announcement, Humana states that its policy will mirror the CMS rule, "as applicable in the Federal Register and relevant CMS guidance." Like CMS, Humana also is requiring the modifier on all applicable claims submitted for services delivered beginning January 1, 2020.

    While the modifier system won't affect payment immediately, both CMS and Humana have stated that they intend to reimburse at 85% of the physician fee schedule for services delivered "in whole or part" by a PTA or OTA beginning in 2022.

    Recognizing that CMS was legally bound to establish a differential system, APTA fought initial drafts of the rule that were needlessly burdensome and seemed to ignore the realities of PT and PTA practice. The final rule included several modifications either suggested or supported by APTA, and the association continues to advocate for changes to the system.

    APTA will meet with Humana representatives to address the adoption of the modifiers and the payment differential and will work to limit the adoption of this policy by other payers.

    APTA offers a quick guide to using the PTA modifier and provides more resources on the differential at the APTA fee schedule webpage.

    APTA's Physical Therapy Outcomes Registry Again Receives QCDR Designation for MIPS Reporting, Adds New Measures

    APTA's Physical Therapy Outcomes Registry has been approved for the fourth year in a row by the U.S. Centers for Medicare and Medicaid Services as a qualified clinical data registry, or QCDR. This designation means that participating physical therapists can submit Merit-based Incentive Payment System — MIPS — reporting data to CMS directly from the registry. QCDR approval recognizes APTA's demonstrated expertise in quality measure development.

    The Physical Therapy Outcomes Registry supports 19 Quality Payment Program measures, 11 QCDR measures, and two electronic clinical quality measures. CMS requires that the electronic clinical quality measures must be reported using certified electronic health record technology, also known as CEHRT.

    As of January 2019, PTs who provide services under Medicare Part B who meet qualifying criteria must participate in either MIPS or an Advanced Alternative Payment Model (Advanced APM). PTs who participate in the Registry can meet MIPS requirements in both the Quality and Improvement Activities categories. Submitting data via a QCDR also earns "bonus" points in the Promoting Interoperability category, which is not yet required for PTs.

    Whether or not PTs participate in MIPS, according to Heather Smith, PT, MPH, APTA's director of quality, APTA’s registry is a valuable tool for optimizing patient outcomes.

    "Participants have found that registry data has opened their eyes to areas for improvement, and even informed changes to the way they deliver care," Smith said. "Registry analytics allow therapists to objectively understand how their practice patterns and interventions are impacting patient outcomes."

    Registry users can access nonproprietary outcomes measures supported by CMS, as well as specific measures shared from other QCDRs.

    By directly integrating with EHRs, the registry enables PTs — whether or not they participate in MIPS — to leverage their existing EHR data to track and benchmark outcomes, apply dashboard insights to improve quality of care, and demonstrate the value of physical therapist services to payers and providers. For more information about the Physical Therapy Outcomes Registry, visit www.ptoutcomes.com.

    Headed to the APTA Combined Sections Meeting in February? Visit the APTA Pavilion in the Exhibit Hall to learn more about how the registry can benefit your practice. Related education sessions include "Demonstrating Value: Using Clinical Data and Databases to Improve Outcomes for Patients and the Population" and "Through the Looking Glass: What Are the Emerging Payment and Quality Issues?"

    Time to Act: Surprise Coding Complication Ignores Realities of PT Practice and Must be Changed


    NOTE: While comments to this story are welcome, if you want to add your voice to the advocacy effort, please follow the "what you can do" instructions in the last paragraph to contact the NCCI contractor directly. Thanks!


     The US Centers for Medicare and Medicaid Services (CMS) unveiled an unwelcome New Year's Day surprise for outpatient therapy providers, including private practitioners and facility-based settings, when it announced it will no longer allow two frequently used therapy billing codes to be used in combination with evaluation codes. It's a decision that flies in the face of standard PT practice and effective patient care—and CMS and the National Correct Coding Initiative (NCCI) contractor need to hear that perspective loud and clear, from as many stakeholders as possible as soon as possible.

    At issue are current procedural terminology (CPT) codes 97530 (therapeutic activities) and 97150 (therapeutic procedures, group, 2 or more individuals) which, until January 1, were allowed to be billed on the same day as physical therapy or occupational therapy evaluation. Under new CMS NCCI edits, however, that's no longer allowed. And in a further complication, the latest NCCI edits also require use of the 59 modifier—the modifier that's used to indicate that a code represents a service that is separate and distinct from another service to which it is paired—whenever code 97140 (manual therapy) is billed with an evaluation.

    [Editors' note: to view the full list of edits that went into effect January 1, visit the CMS PTP coding edits webpage, and scroll down to the "related links" area, where you can select your setting to find out what's changed.]

    The problem, according to APTA Director of Regulatory Affairs Kara Gainer, is that the changes ignore accepted PT practice, which often includes the startup of care on the same day as evaluation, as well as continuation of care on the same day as revaluation.

    "The whole NCCI process is supposed to put a check on payment for codes that represent overlapping services," Gainer said. "These edits not only miss that mark, they actually have the effect of restricting patient access to the most effective, efficient care, and risking a patient's ability to achieve the best possible outcomes."

    APTA usually receives notice of intended NCCI edits well in advance. That didn't happen in this case, making it imperative that the association, its members, and other stakeholders take action quickly to convince NCCI to reverse its decision. APTA is in communication with Capitol Bridge, LLC, CMS' NCCI contractor, as well as with the American Medical Association, to press for a resolution to the problem.

    What you can do: APTA has developed a comment letter template that you can fill in with your personal information and email to Capitol Bridge, LLC, at NCCIPTPMUE@cms.hhs.gov. Make your voice heard.

    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.

    CMS Rule on Hospital Price Transparency Sets the Stage for Major Shift in Public Access to Charges for Services

    In this review: Medicare and Medicaid Programs: Price Transparency Requirements for Hospitals to Make Standard Charges Public (final rule)
    Effective date: January 1, 2021
    CMS fact sheet

    The big picture: Hospitals will face more stringent requirements to disclose charges for items and services—including physical therapy—in a consumer-friendly, online form. Hospitals aren't happy about it.
    A final rule from the US Centers for Medicare and Medicaid Services (CMS) makes it clear that the agency will move ahead in its efforts to make hospital cost data more accessible to consumers. Beginning January 1, 2021, hospitals will be required to share a much more detailed range of charges, including gross charges, charges negotiated with a third-party payer, charges for cash payment from individuals, and minimum and maximum negotiated charges. The publicly accessible data must cover at least 300 services that patients can schedule in advance—known as "shoppable" services—and while hospitals have some leeway as to which service charges are included, they are required to lists charges for a core set of 70 services, including physical therapy, specifically therapeutic exercise (CPT 97110).

    The American Hospital Association, the Federation of American Hospitals, the Association of American Medical Colleges, and the Children's Hospital Association announced that they will challenge the final rule in court, writing in a joint statement that the rule "will introduce widespread confusion, accelerate anticompetitive behavior among health insurers, and stymie innovations in value-based care delivery."

    Notable in the final rule

    The total number of disclosed services must be at least 300. If a hospital doesn't offer 1 or more of the 70 required services, it must substitute an additional shoppable service so that the total list equals at least 300 services.

    Listings must be easy-to-understand, presented in a "machine readable" format, and updated annually. In addition to the charge data being available for free on a public website, the lists must be in formats that can be "read" by computers (as opposed to pdf files, for example), and must use clear language in descriptions of services, including information that makes it easy to identify the particular hospital location associated with each listed service.

    The definition of "standard charge" is broad. Under the new rule, the "standard charges" that must be shared include cash prices, charges negotiated with individual payers, and de-identified minimum and maximum charges.

    Billing codes must be included. Listings must include relevant codes such as Current Procedural Terminology codes, Healthcare Common Procedure Coding System codes, and diagnostic-related group codes, among others.

    The rule will require health insurers to be more transparent, too. The rule extends to group health plans and health insurers, which will be required to allow public access to out-of-pocket cost information for all covered items and services, as well as to payment rates for both in and out-of-network providers.

    Final Outpatient Payment Rule From CMS Eases Supervision, Moves Ahead With 'Site Neutral' Payment Despite Lawsuit

    In this review: Medicare Program: Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs (final rule)
    Effective date: January 1, 2020
    CMS Fact Sheet

    The big picture: Continued trends toward easing supervision burdens, and a contested effort to reduce payment variation (that doesn't really affect PTs)
    The US Centers for Medicare and Medicaid Services (CMS) is pushing for an outpatient environment in which overall payments vary less according to who owns a facility, according to the final Medicare outpatient payment system rule set to go into effect on January 1, 2020.

    The rule moves ahead with CMS efforts to establish a "site neutral" payment model in its payment for physician services, doing away with a system that pays so-called "off campus" hospital-owned facilities more than it does their independent equivalents. The plan hit a recent snag when a federal judge refused to impose a stay on a court ruling in September in favor of plaintiffs, including the American Hospital Association, that sought to block the rollout of the site-neutral plan. CMS stated in the final rule’s fact sheet that they do not believe “it is appropriate at this time to make a change to the second year of the two-year phase-in of the clinic visit policy. The government has appeal rights, and is still evaluating the rules and considering, at the time of this writing, whether to appeal from the final judgment.” Because physical therapy services in outpatient settings are paid under the CMS physician fee schedule, PTs aren't affected by CMS' hoped-for change.

    The final rule also includes an APTA-supported move toward easing supervision burdens placed on hospitals by way of changed supervision requirements for outpatient therapeutic services in all hospitals. Beginning January 1, the requirements will move from "direct" supervision to "general" supervision, meaning that while a given procedure may be furnished under a physician's overall direction and control, the physician's physical presence no longer will be required during the performance of the procedure. The change is viewed as a particularly positive one for critical-access hospitals and other facilities in underserved areas.

    Also notable in the final rule

    • Payment rates for outpatient hospitals and ambulatory surgical centers (ASCs) will increase by 2.7%.
    • CMS said it will consider the stakeholder feedback it received on its proposal to add 4 safety measures to the Outpatient Quality Reporting Program (Hospital OQR Program) in the future. These measures already are required of ASCs: patient falls, patient burns, wrong site/side/procedure/implant, and all-cause hospital transfers/admissions.
    • CMS recognized that it received over 1,400 comments regarding its proposal to require hospitals to make their standard charges public for all items and services, and stated that it would summarize and respond to these comments in a future final rule.

    Worth watching: prior authorization
    Prior authorization also figures into the new rule, which requires preapproval for 5 cosmetic procedures including vein ablation. While this doesn't directly affect services associated with physical therapy, APTA advocates in general against prior authorization requirements that slow the delivery of care and limit patient access to appropriate interventions. APTA regulatory affairs staff will continue to pay particular attention to future rulemaking in this area.

    Final DMEPOS Rule Attempts to Shape a Clearer, More Predictable System

    In this review: Medicare Program: Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule Amounts, DMEPOS Competitive Bidding Program (CBP) Amendments, Standard Elements for DMEPOS Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements (final rule)
    Effective date: January 1, 2020
    CMS Fact Sheet

    The big picture: A rule that attempts to keep up with the rapid development of new and different DMEPOS
    The US Centers for Medicare and Medicaid Services (CMS) aims to make payments for devices a little more predictable in light of the ever-increasing—and ever-advancing—range of options available to providers and patients. CMS intends to accomplish this goal by way of a "comparable item analysis" system that the agency thinks will help make it easier to nail down exactly what Medicare will pay for those devices. The new rule takes effect January 1, 2020.

    The idea is that when old and new items are comparable, CMS will use the fee schedule amounts for the existing older item to determine payment amounts for the new one. If there are no comparable older items, CMS says it will base payment on commercial pricing data such as internet pricing and supplier invoices. Those prices for the noncomparable items won't necessarily stay fixed: if commercial pricing drops, so will CMS rates. CMS identified 5 main categories upon which new DMEPOS items can be compared with older ones: physical components, mechanical components, electrical components (if applicable), function and intended use, and additional attributes and features.

    Also notable in the final rule

    • CMS is revamping requirements around face-to-face meetings between providers and patients in need of DMEPOS that "may have created unintended confusion for stakeholders." The current requirements—essentially a collection of ad-hoc provisions that have accrued over the past 13 years—will be replaced with what CMS describes as a "single list of DMEPOS items potentially subject to a face-to-face encounter and written orders prior to delivery, and/or prior authorization requirements."
    • CMS will no longer require contract suppliers to notify CMS 60 days in advance of a change of ownership (CHOW). Instead, CMS will require notification no later than 10 days after the effective date of the CHOW. Additionally, CMS is removing the distinction of a “new entity,” but the rule retains the successor entity requirements.

    Final 2020 Fee Schedule: CMS Relents on PTA Differential System for 2020; Presses on With Planned 8% Cut to Physical Therapy in 2021

    A major win, and a major challenge: that's what APTA and the physical therapy profession are facing now that the US Centers for Medicare and Medicaid Services (CMS) has released the final 2020 Medicare physician fee schedule. While the agency seems to have listened to critics and made significant positive changes to the way it will calculate payment when therapy services are delivered "in part" by a physical therapist assistant (PTA), it inexplicably ignored thousands of comments, including a letter from members of Congress, calling for reconsideration of a proposed 8% cut for physical therapy payment and host of other disciplines in 2021. The planned cuts set the stage for intense advocacy efforts by APTA and other professional organizations representing a wide range of health professions including psychologists, occupational therapists, ophthalmologists, chiropractors, and clinical social workers. [CMS has also issued a fact sheet and press release on the final rule.]


    The win: CMS backed off from an ill-advised system to calculate when therapy services delivered "in part" by a PTA would trigger 15% lower Medicare Part B payments beginning in 2022.

    Background: It wasn't CMS' idea to create a code modifier (CQ or CO) to denote services delivered "in part" by a PTA or occupational therapy assistant (OTA)—that was something introduced by federal law—but the way CMS proposed to roll out the system lacked understanding for the real world of physical therapy care delivery. In addition to the proposal being misinformed, it was overly burdensome, and would've likely reduced patient access to needed care.

    What was proposed: CMS forwarded the idea of a "de minimis" 10% standard that would trigger use of the modifier whenever a PTA or OTA provided outpatient therapy services for 10% or more of the total time spent furnishing the service. The proposal stipulated, among other things, that the modifiers be applied to the claim when services were delivered concurrently with a physical therapist (PT), and required all codes to be accompanied by a written explanation of why the modifier was or wasn't used.

    What's in the final rule: APTA and its members engaged in an intensive advocacy effort around these provisions, and CMS reconsidered its approach, adopting a system that's consistent with many of the association's recommendations. Among the wins in the new rule:

    • When the PT is involved for the entire duration of the service and the PTA provides skilled therapy alongside the PT, the CQ modifier isn't required.
    • When the same service (code) is furnished separately by the PT and PTA, CMS will apply the de minimis standard to each 15-minute unit of codes—not on the total PT and PTA time of the service, allowing the separate reporting, on 2 different claim lines, of the number of units to which the new modifiers apply and the number of units to which the modifiers do not apply.
    • The proposed documentation requirements are scrapped.

    "This is a huge win for physical therapy under Medicare," said Kara Gainer, APTA director of regulatory affairs. "When we speak with a unified voice, make a clear case for our position, and offer viable options, we can make a difference with CMS. In this case, the difference our members made was huge."


    The challenge: For now, CMS is sticking to its proposal to cut payment for physical therapy providers by an estimated 8% beginning in 2021.

    Background: CMS thinks that values for office/outpatient evaluation and management (E/M) codes are too low—an opinion that APTA doesn't necessarily oppose.

    What was proposed: The Medicare physician fee schedule is budget-neutral. To increase values for the E/M codes while maintaining budget neutrality under the fee schedule, CMS proposed cuts to other codes to make up the difference beginning in 2021. Under the plan, physical therapy could see code reductions that may result in an estimated 8% decrease in payment. Other professions stand to lose as well: for example, ophthalmology would see a 10% cut, audiology would face a 6% reduction, chiropractic care would drop by 9%, and clinical social workers would see payment decline by 6%. In total, 36 specialties are facing reimbursement reductions in 2021. However, CMS has not yet determined the actual cuts to each code.

    What's in the final rule: Despite a flood of comments into CMS—more than 10,000 from APTA members alone—and a collaborative advocacy effort among professional organizations that included a letter signed by 55 members of Congress opposing the cuts and a provider sign-on letter signed by 10 associations, CMS left the proposal untouched in the final rule.

    CMS briefly acknowledges the reaction it received, writing that "we understand commenters' concerns with the magnitude of the redistributive adjustment necessary." The agency explains that it was reluctant to make any changes to the plan given that "we do not know the magnitude of redistribution resulting from other policies we may adopt through rulemaking before then," and characterizes a table of proposed 2021 code valuation adjustments included in the final fee schedule as being "for illustrative purposes only."

    "APTA made it very clear to CMS that the association and its members oppose the cuts proposal for 2021, and Congress reinforced APTA’s message," said Katy Neas, APTA executive vice president of public affairs. "APTA and its members, along with literally thousands of other health care providers, made compelling arguments and offered thoughtful alternatives that were seemingly completely ignored as the final rule was drafted. We are taking CMS very seriously when it says that this plan is subject to change. We've brought the association's voice to bear on the PTA modifier issue, and CMS listened. Over the next 12 months, we will leverage every possible opportunity – working with Congress and CMS --to change this flawed policy."


    More from the fee schedule: MIPS continues to expand, and CMS continues to move toward a more streamlined system.

    The final rule also makes changes to the Merit-based Incentive Payment System (MIPS). Starting in 2020, CMS will add measures for diabetic foot and ankle care; peripheral neuropathy: neurological evaluation and prevention evaluation of footwear; screening for clinical depression and follow-up plan; falls screening and plan of care, elder maltreatment screen and follow-up plan; preventive care and screening: tobacco use: screening and cessation intervention; dementia: cognitive assessment, functional status assessment, and education and support of caregivers for patients with dementia; falls: screening for future fall risk; and functional status change for patients with neck impairment. The rule also removes 2 measures: pain assessment and follow-up, and functional status change for patients with general orthopedic impairments.

    Other changes to MIPS include the following:

    • Data completeness for the 2020 performance year will be set at a 70% sample for both Medicare Part B claims-based reporting and clinician or group reporting via a registry.
    • Groups will be able to attest to an improvement activity when at least 50% of the MIPS-eligible clinicians perform the activity, at a rate of at least 50% of the group's providers with a National Provider Identifier (NPI) performing the same activity for the same 90 continuous days in the performance period.
    • The Promoting Interoperability category will continue to be reweighted for PTs by CMS in 2020, meaning that PTs won't be scored in this category.
    • MIPS-eligible clinicians with a final score of 45 will receive a neutral payment adjustment in 2020, with the score rising to 60 points for the 2021 payment year. The exceptional performance bonus will be triggered with a score of 85 points in both 2020 and 2021.
    • CMS will also continue its shift to a streamlined version of MIPS, which it has dubbed "MIPS Value Pathways," (MVPs) for 2021 and beyond.

    Also notable in the 2020 PFS: KX modifier thresholds, dry needling, biofeedback codes, negative pressure wound therapy, and more.

    As always, the fee schedule rule is expansive. Here are some quick takes on other 2020 PFS provisions of interest to the physical therapy community.

    The KX modifier gets a slight bump. The threshold amount for use of the KX modifier will rise from $2,040 to $2,080 for physical therapy and speech-language pathology services combined, and by the same amount for occupational therapy services. The targeted medical review threshold remains at $3,000. These changes will be incorporated into APTA's multiple procedure payment reduction (MPPR) calculator, which will be live before January 1, 2020.

    Dry needling codes have been added—but CMS won't be covering them. The final rule adds 2 dry needling codes (1 for insertions in 1-2 muscles, and another for insertions in 3 or more), but the codes will remain unpaid unless a national coverage determination says otherwise. If the codes were covered, CMS believes they should be considered as "sometimes therapy" procedures rather than "always therapy."

    Biofeedback codes are now available as "sometimes therapy." Codes related to biofeedback training of perineal muscles or anorectal or urethral sphincters have been added to the biofeedback family, and valued at .90 work RVU for the initial 15 minutes of treatment and .50 work RVU for each additional 15 minutes of one-on-one contact.

    Negative wound pressure gets coding values. After some 3 years of work, CMS has established relative value units (RVU) and direct practice expense inputs for codes associated with negative wound pressure therapy, with a .41 work RVU for code 97607 (vacuum-assisted drainage collection for total wound surface area of 50 square centimeters or fewer) and .46 work RVU for 97608 (vacuum-assisted drainage collection for total wound surface area of 51 square centimeters or more).

    CMS remains unclear when it comes to PTs' use of remote physiologic monitoring codes. Last year, CMS said qualified health care professionals can furnish and bill for these services, as long as it’s within their scope of practice. APTA interprets this to include PTs, who are included in the American Medical Association’s definition of "qualified health professionals." In response to APTA’s continued request for clarity from the agency, CMS advised that PTs with billing questions related to these codes contact their Medicare administrative contractor(s). In the final rule, CMS says it will "consider these and other questions." Once again, the issue seems to be up in the air.

    Final Home Health Rule Cements PDGM, Allows PTAs to Perform Maintenance Therapy

    When it comes to its most talked-about provisions, the US Centers for Medicare and Medicaid Services' (CMS) final rule for home health payment under Medicare isn't much of a change from the proposed version released earlier this year, meaning that an entirely new payment system will indeed be rolled out beginning January 1. But other parts of the rule have been tweaked—and in several areas, those tweaks represent wins for the physical therapy profession and the patients it serves in home health settings. [In addition to the lengthy final rule, CMS also offers a fact sheet summary.]

    It's official: PDGM is on for 2020.
    There wasn't much debate about whether this would happen, but the final rule eliminates any doubt: the Patient-Driven Groupings Model (PDGM) will be the system under which CMS pays home health agencies (HHAs). It's a big change, and APTA offers extensive information on the details of the model, but the bottom line is that the PDGM moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. The system classifies episodes according to a set of 5 major buckets and subsets within those buckets. Patients are assigned a status within the 5 major areas, and within some of those areas they can be assigned to more detailed clinical categories—the combination of categories assigned to a patient generates a particular case-mix grouping. CMS says it will monitor how HHAs are operating under the PDGM, including the provision of therapy services.

    Overall payments will increase by 1.3%.
    CMS projects an annual increase of about $250 million in payments related to home health.

    "Behavioral adjustments" will still be used—but they won't be as large as proposed.
    In anticipation of the possibility that HHAs will alter their practices to maximize payment under the PDGM, CMS had proposed a "behavioral adjustment" that reduced payments by 8.01%. The final rule lowers the negative adjustment to 4.36%.

    PTAs will be able to perform maintenance therapy under the home health benefit.
    The final rule follows through on an APTA-supported proposal to allow physical therapists assistants (PTAs) and occupational therapy assistants (OTAs) to perform maintenance therapy services under a maintenance program established by a qualified therapist, as long as the services fall within scopes of practice in state licensure laws. In addition to supervising the services provided by the PTA or OTA, the qualified therapist still would be responsible for the initial assessment, plan of care, maintenance program development and modifications, and reassessment every 30 days.

    A question about pain still will be available to patients.
    In addition to removing a quality-reporting measure on to pain interfering with activity from the Quality Reporting Program, CMS also proposed eliminating a home health consumer survey question about whether the patient and provider had discussed pain in the past 2 months. APTA and other organizations pressed for that question to remain, and CMS relented. The pain interfering with activity quality measure has been removed, however.

    Split payments are going away, and Requests for Anticipated Payment (RAPs) will be gone by 2022—but a modified RAP process will be in place beginning in 2021.
    CMS is phasing out the split percentage payment approach beginning in 2020. The split percentage payment amount, paid in response to a RAP, will shift from an upfront 60%-initial, 50%-subsequent payment for each 60-day period to 20% for both initial and subsequent 30-day periods of care. Then, beginning in 2021, there will be no upfront payment made in response to a RAP; however, all HHAs will be required to submit a "no-pay” RAP every 30 days to alert the claims processing system that the beneficiary is under a home health period of care. HHAs must submit the “no-pay” RAP within 5 calendar days of each 30-day period or be subject to a late penalty. Beginning in 2022, CMS will eliminate RAPs and instead require HHAs to submit a Notice of Admission (NOA) every 30 days; agencies must do so within 5 calendar days of each 30-day period or be subject to a payment penalty. CMS says that because they are removing upfront payment associated with the RAP, the agency is relaxing the information needed to submit the “no-pay” RAP and subsequent NOA.

    Want more on PDGM? Sign up for the November 20 APTA "Insider Intel" phone-in session, where the home health system will be discussed along with the final Medicare physician fee schedule.

    UnitedHealthcare to Expand Program Waiving Copays, Deductibles for Physical Therapy for LBP

    Momentum around better insurer coverage of physical therapy continues to build at UnitedHealthcare (UHC), which announced that it's moving ahead to expand a pilot project that waives copays and deductibles for 3 physical therapy sessions for patients with new-onset low back pain (LBP). The pilot follows a multiyear collaboration between APTA, OptumLabs®, and UHC.

    The program is targeted at UHC enrollees in employer-sponsored plans who experience new-onset LBP and seek care from an outpatient in-network provider. The program fully covers up to 3 visits to a physical therapist (PT) or chiropractor in addition to visits normally covered. When the program was rolled out in June, it was limited to plans sponsored by employers of more than 50 employees in Florida, George, Connecticut, North Carolina, and New York. The expanded pilot, which begins January 1, 2020, will extend to self-funded plans with 2 to 50 employees in Alabama, Arkansas, Florida, Georgia, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia.

    APTA has been working with UHC and OptumLabs to investigate both the efficacy of physical therapy as a first treatment option for LBP and the effects insurer payment policies have on patient access to more conservative approaches to the condition. Those efforts yielded 3 research articles: a study affirming that higher copays and payer restrictions steer patients away from conservative LBP treatments; an analysis that found lower odds of early and long-term opioid use among patients who see a PT first for LBP; and an investigation that linked unrestricted direct access to a PT for LBP to lower health care utilization and costs than would occur with provisional access to physical therapy. APTA cosponsored all 3 studies.

    "The evidence supporting the use of physical therapy as a first-line, widely accessible treatment for low back pain continues to grow, and insurers like UnitedHealthcare are paying attention and moving from analysis into action," said Carmen Elliott, APTA's vice president of payment and practice management. "APTA's collaboration with UHC and Optum has helped UHC establish some on-the-ground changes that we hope will pave the way for a true sea change in the way insurers think about the value of physical therapy."