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  • The Post-Therapy Cap System: 5 Basics You Need to Know

    When Congress adopted a federal spending package that included the elimination of the hard cap on Medicare therapy services, it didn't just remove a rule—lawmakers also adopted a new system of payment thresholds and triggers, and a differential payment rate for physical therapist assistants (PTAs) and occupational therapy assistants (OTAs), among other things.

    APTA supported an end to the hard cap, which is a significant win for the most vulnerable Medicare patients, but other parts of the system that replaced it are problematic.

    The elimination of the hard cap is retroactive to January 1, 2018, but not all details of the post-cap system have been worked out, and it's possible that some may change before their implementation dates. In the meantime, here are the basic elements of the new system.  

    1. It boils down to a threshold for using KX modifiers and a trigger for possible medical review.
    The basic idea is this: outpatient therapy under Medicare now has a $2,010 threshold; services delivered beyond that require a KX modifier indicating that the service meets the criteria for a payment exception. When therapy reaches $3,000, it's subject to possible targeted medical review—although CMS didn't receive any additional funding to conduct these reviews.

    2. Physical therapy and speech-language pathology still are lumped together in the thresholds.
    Just as in the previous payment system that included a hard cap and exceptions process, the new system doesn't separate physical therapy from speech-language pathology in establishing thresholds. Those $2,010 and $3,000 limits are for physical therapy and speech-language pathology therapy combined—another element opposed by APTA.

    3. The thresholds apply to all part B outpatient therapy services—including services provided by hospital outpatient departments.
    For the brief time beginning in January when the therapy cap was in place, hospital outpatient facilities were not subject to the cap. That changed with the adoption of the budget package, and now these departments or clinics are subject to the thresholds: $2,010 for use of the KX modifier and $3,000 for potential targeted medical review.

    4. The PTA payment differential will start in 2022—along with a special claims designation.
    In the post-cap payment system, outpatient therapy services performed by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) will be reimbursed at 85% of the Medicare physician fee schedule—a change opposed by APTA. However, that's not set to happen until 2022.

    For now, claims do not include a way to designate whether a service was delivered by a PTA, but that too will change by 2022, when CMS will develop a modifier to make that distinction. Between now and then, look for opportunities to comment on proposed rules around this process, along with guidance and more details as they develop.

    5. Home health also will be subject to the PTA payment differential, absent a plan of care.
    The 85% payment differential for services provided by a PTA or OTA will apply to home health care provided to Medicare part B beneficiaries—but only when a home health plan of care is not in effect. The budget deal that resulted in the end to the hard cap also established other new rules for home health.PT in Motion News recently reported on these additional changes.

    Now Available: Recording of 'Insider Intel' Session on Therapy Cap, Home Health, More

    The budget deal reached by Congress earlier this month included changes that affected not only the hard cap on therapy services under Medicare but also a host of other health care-related issues, including home health. Are you ready for what's coming?

    "Insider Intel" to the rescue.

    Now available: a recording of an APTA "Insider Intel" phone-in session devoted to the Medicare landscape since the budget deal. Hosted by staff from the APTA regulatory affairs unit, the 30-minute session covered where things stand and included a question-and-answer session.

    CMS Offers Settlement Option for Providers With Denial Appeals in Limbo

    The US Centers for Medicare and Medicaid Services (CMS) is offering some providers a chance to settle backlogged claims denial appeals at 62% of net allowed amounts, but there are limits and deadlines involved.

    Called the "Low Volume Appeals Initiative," the program is part of a CMS attempt to clear a glut of Medicare appeals piling up at the Office of Medicare Hearings and Appeals (OMHA) and the Medicare Appeals Council levels.

    The program is limited to providers who have fewer than 500 appeals with no single appeal exceeding $9,000. Providers begin the process by submitting an "expression of interest" form to CMS. Providers with National Provider Identifiers (NPIs) ending in an even number have from between now and March 9 to turn in the form; the window for providers with NPIs ending in odd numbers will open on March 12 and close on April 11.

    To qualify for the settlement, the appeal must meet certain criteria:

    • The appeal was pending before the OMHA and/or council level of appeal as of November 3, 2017.
    • The appeal has a total billed amount of $9,000 or less.
    • The appeal was properly filed at the OMHA or council level as of November 3, 2017.
    • The claims included in the appeal were denied by a Medicare contractor and remain in a fully denied status in the Medicare system.
    • The claims included in the appeal were submitted for payment under Medicare Part A or Part B.
    • The claims included in the appeal were not part of an extrapolation.
    • The appeal is still at the OMHA or council level of review when an administrative agreement is fully executed.

    The final agreement would cover all claims that are approved for settlement. Once finalized by CMS and the provider, Medicare Administrative Contractors (MACs) will total the claim amounts and make a single total payment within 180 days of CMS' signature on the agreement.

    Questions about the initiative can be emailed to MedicareSettlementFAQs@cms.hhs.gov.

    Home Health Faces Challenges in Wake of Budget Deal

    A major advocacy issue for the physical therapy profession was resolved with the elimination of the hard cap on therapy services under Medicare, but other provisions in the massive budget bill that ended the hard cap have created different challenges. Case in point: in the home health arena, patients and providers are facing budget cuts and a reduction in payment units, with the possibility of even more dramatic—and potentially damaging—changes to come.

    The final budget package approved by Congress last week includes provisions reducing the home health care unit of payment to 30 days from its current 60-day unit. In addition, the home health market basket percentage—the amount of money CMS plans devote to goods and services in a particular area—will be 1.5%. Both changes are slated to start in 2020, and other potential harmful moves could be on the horizon. The changes, opposed by APTA, were included late in lawmakers' negotiations around the budget deal with no opportunity for input from stakeholders. The new provisions also eliminate therapy thresholds that affect episode payment calculations.

    The payment unit changes echo provisions included in CMS' failed attempt to adopt what it called the Home Health Grouping Model (HHGM), a sweeping overhaul of the home health payment system proposed the summer of 2017. APTA and other groups opposed nearly all of the proposals associated with HHGM, including the switch to the 30-day payment unit. In a letter to CMS, APTA described the 30-day unit as a change that would produce a "perverse financial incentive for providers to inappropriately decrease lengths of stay and/or avoid admitting patients who will require care beyond the 30-day episode." CMS dropped its efforts to adopt HHGM in the fall.

    Although the 30-day unit adopted in the budget deal is similar to what was proposed in HHGM, there's 1 major difference: the provision now in place is budget-neutral. The 30-day unit proposed by CMS through the HHGM would have resulted in significant reductions in reimbursement.

    But that doesn't mean the ideas behind HHGM are dead. In fact, says Kara Gainer, APTA's director of regulatory affairs, the budget deal also includes a provision directing the Department of Health and Human Services (HHS) to develop a new case-mix system that can be implemented by 2020. The concern of APTA and other home health supporters is that HHS will resurrect many of the changes proposed in the HHGM.

    "We expect that HHS will attempt to create a case-mix system similar in nature to the HHGM," Gainer said. "However, HHS has said that its revisions will be based on feedback from a technical expert panel." That panel met on February 1 and included a representative from APTA. Gainer is hoping that at least 1 more panel meeting will be held in 2018.

    So does Diana Kornetti, PT, MA, president of the APTA Home Health Section. Kornetti is also a credentialed home care coding specialist.

    "Right now, it appears that only 1 technical expert panel meeting is required by law during 2018, and that's already happened," Kornetti said. "This is the first thing that needs to change. There is no guarantee that the home health industry and its stakeholders will have any future opportunity to review and discuss the issues and concerns that will arise."

    According to Kornetti, should stakeholders get that opportunity, the case for the right kinds of changes to the home health payment will be much stronger if it's backed by documented outcomes for physical therapy.

    "Patient acuity is critical," Kornetti said. "Capturing correct and thorough data, using objective measures, will be increasingly important to establishing an accurate payment for physical therapist services. We must speak the language of outcomes moving forward as a profession—our services must show our impact on reduction of costs, while continuing to strive for increasing clinical quality."

    With the therapy cap issue settled, APTA will focus its advocacy efforts in different ways, Gainer explained. The threats to home health will be 1 of the association's targets.

    But as with any other attempt to get policymakers to listen, the effort will require participation from physical therapists and physical therapist assistants, Kornetti added.

    "A key principle in our code of ethics speaks to advocacy for those we serve," Kornetti said. "It has never been more important for the postacute physical therapist and physical therapist assistant to become informed and participate in this process. One rung of our ladder toward a fully autonomous profession is having representation at the table where decisions are being made."

    The Good Stuff: Members and the Profession in the Media, February 2018

    "The Good Stuff," is an occasional series that highlights recent, mostly local media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    “I went to Stanford, I was a professor at Cal Fresno. I had patients, friends, students I learned so much from. I’ve done this all because I’ve been pushed. I need to do as much as I can to prove I’m a good person. I still wasn’t whole." - Helen Grace James, PT, who won her federal lawsuit to receive an honorable discharge from the US Air Force after being expelled in 1955 for being a lesbian. (The Washington Post)

    For individuals who take a break from exercising, Ryan Balmes, PT, DPT, answers the question, "Where did all my muscles go?" (Esquire)

    Noah Greenspan, PT, DPT, provides a tip on how to keep the flu from turning into pneumonia. (Shape)

    Sharon Wentworth, PT, DPT, discusses the challenges of helping young female athletes avoid ACL tears. (USAToday app. website)

    Jessica Hill, PT, DPT, shares "4 tips that will help you start your day productively." (Gotham)

    Robert Gillanders PT, DPT, comments on 5 common running injuries and how to avoid them. (US News and World Report)

    The Illinois Physical Therapy Association has launched a copay advocacy effort. (WCIA13 News, Champaign, Illinois)

    Margaret Schenkman, PT, PhD, FAPTA, sees possibilities for vigorous exercise in the treatment of Parkinson disease. (The Denver Post)

    Marianne Ryan, PT, BS, outlines what women can expect of their bodies after giving birth. (NYMetroParents)

    Boss magazine lists physical therapy as 1 of the top 7 trending jobs of 2018. (Boss)

    Brett Walker, PT, physical therapist for the Chicago White Sox, paid a visit to his alma mater, University of Mary, in North Dakota. (Bismarck, North Dakota Tribune)

    Karena Wu, PT, DPT, suggests 4 exercises to combat text neck. (NBC News online)

    Heather Henry, PT, DPT, challenges the no pain/no gain theory. (US News and World Report)

    "Speech and physical therapy is poorly recognized for its benefits [to individuals with Parkinson disease]. Too often doctors just prescribe drugs." - Zoltan Mari, MD, on the possible treatment courses for singer Neil Diamond, who recently announced his retirement due to Parkinson disease. (next avenue)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    CMS Issues Coding, Other Details on Supervised Exercise Therapy for Peripheral Artery Disease

    US Centers for Medicare and Medicaid Services (CMS) has released details on how it will process claims made as a result of its decision to cover supervised exercise therapy (SET) in the treatment of peripheral artery disease (PAD).

    The expansion covers physician-referred SET for up to thirty-six 30- to 60-minute sessions over a 12-week period. The sessions must be conducted in a physician's office or outpatient facility, and must be delivered by "qualified auxiliary personnel" that includes physical therapists, nurses, and exercise physiologists. Supervision is to be conducted by a physician or "non–physician practitioner"—a physician assistant, or nurse practitioner/clinical nurse specialist.

    Although CMS announced the change in May 2017, it only recently released the nuts-and-bolts around provider coding and claims processing for Medicare Administrative Contractors (MACs). Details are available from 3 resources:

    To receive coverage for SET, Medicare beneficiaries with PAD must have a face-to-face visit with a physician and be referred for the program. The physician visit must also include education on cardiovascular disease and PAD risk reduction. Medicare Administrative Contractors can allow for more sessions or a second set of 36 sessions, but these additional sessions require another referral.

    New APTA Podcast Series Explores Big Picture and Details of Value-Based Care

    Everyone's talking about "value-based care," but what does the concept really mean, and how will it affect your practice? That's the subject of a new 21-part podcast series now available for download from APTA.

    The free series, delivered in easily digestible 5- to 7-minute presentations, moves from big-picture questions such as "What is value?" and "Why do we need quality measures?" to the nitty-gritty of the Merit-based Incentive Payment System (MIPS) and advanced Alternative Payment Models (APMs). Both MIPS and advanced APMs are pillars of the US Centers for Medicare and Medicaid Service's Quality Payment Program (QPP), a comprehensive shift away from the fee-for-service model of care.

    The series is part of APTA's efforts to educate physical therapists and physical therapist assistants on changes that currently are voluntary, but could be mandatory as early as 2019 and merit attention now. A link to the podcasts, as well as a wide range of other resources on value-based care, can be found on the association's Value-Based Care webpage.

    A Permanent Fix to the Therapy Cap: Improved Access for Medicare Patients Comes With Pending APTA-Opposed Cut to PTA Payment

    The looming threat of a hard cap on physical therapy services under Medicare has been eliminated.

    As part of a sprawling bipartisan budget deal passed today, Congress enacted a permanent solution to the problematic hard cap on outpatient physical therapy services under Medicare Part B, ending a 20-year cycle of patient uncertainty and wasteful short-term fixes.

    Ending the hard cap has been a high priority for APTA since its introduction in 1997 as part of the Balanced Budget Act. Legislators' backing for repeal reached a tipping point in 2017, when lawmakers developed a bipartisan, bicameral agreement to end the cap. Congress failed to enact that deal in 2017, but elements of the plan are included in the 2-year budget that was approved today.

    That's the good news. The bad news is that Congress chose to offset the cost of the permanent fix (estimated at $6.47 billion) with a last-minute addition of a payment differential for services provided by physical therapist assistants (PTAs) and certified occupational therapy assistants (COTAs) compared with payment for the same services provided by physical therapists (PTs) and occupational therapists (OTs), respectively. The payment differential, which was strongly opposed by APTA and other stakeholders, states that PTAs and OTAs will be paid at 85% of the Medicare physician fee schedule beginning in 2022.

    That pending payment differential under Medicare is somewhat comparable to that between physician assistants and physicians, but it was added to the budget bill late and without warning. It wasn’t part of the 2017 bipartisan agreement legislators reached, nor was it part of any discussions or negotiations on Capitol Hill since then.

    When the proposed differential was added to the budget deal late Monday night, the association quickly reached out to congressional offices with proposed amendments. None were accepted. Friday morning, Congress passed the massive budget legislation that includes increases for military and domestic spending, adding an estimated $320 billion to the federal budget deficit.

    “Stopping the hard cap is a victory for our patients, and for our dedicated advocates,” said APTA President Sharon L. Dunn, PT, PhD, board-certified orthopaedic clinical specialist. “For 2 decades we have held back the hard cap through repeated short-term fixes—17 in total—that were achieved each time only through significant lobbying efforts by APTA and other members of the Therapy Cap Coalition. In that time, the hard cap was a genuine and persistent threat to our most vulnerable patients, a threat we saw realized earlier this year when Congress failed to extend the therapy cap exceptions process. Today that threat has been eliminated.”

    Dunn said the January 1, 2022, implementation date for the opposed PTA payment cut provides time to explore solutions with the Centers for Medicare and Medicaid Services (CMS) as it develops proposed rules.

    “APTA will leverage its congressional champions, the APTA Public Policy and Advocacy Committee, and the PTA Caucus on strategies to address the CMS activities,” Dunn said. “Our collective efforts will drive the association’s work to ensure that guidance to implement the new policy is favorable to PTAs and the profession, while ensuring access is not limited for those in need of our services.”

    The legislation enacted today provides a fix for the therapy cap by permanently extending the current exceptions process, eliminating the need to address this issue from year to year. Among the provisions included in the new policy:

    • Claims that go above $2,010 (adjusted annually) still will require the use of the KX modifier for attestation that services are medically necessary.
    • The threshold for targeted medical review will be lowered from the current $3,700 to $3,000 through 2027; however, CMS will not receive any increased funding to pursue expanded medical review, and the overall number of targeted medical reviews is not expected to increase.
    • Claims that go above $3,000 will not automatically be subject to targeted medical review. Instead, only a percentage of providers who meet certain criteria will be targeted, such as those who have had a high claims denial percentage or have aberrant billing patterns compared with their peers.

    Over the coming days, APTA will provide additional details on the budget deal, including the impact on home health. For home health, the deal includes positives related to rural add-ons, a market basket update increase of 1.5% in 2020, and use of home health medical records for determining eligibility. However, it also requires a switch from a 60-day to a 30-day episode in 2020 and eliminates the use of therapy thresholds in case-mix adjustment factors.

    “While this package does not afford APTA with everything we would have liked, we should take a moment to celebrate closing the door on a 20-year advocacy effort that has challenged our ability to ensure timely and appropriate services to patients,” Dunn said. "Reaching this milestone affords APTA the opportunity to expand our advocacy agenda to implement more fully our vision to transform society by optimizing movement to improve the human experience.”

    Now's Your Chance to Step up to APTA Committee Service

    Have you ever wondered how the McMillan Lecturer is selected? Are you a strategic business thinker able to help move your association’s finances forward? Are you ready to serve your profession?

    The call for volunteers to serve on APTA committees is now open. Members interested in serving on the Ethics and Judicial, Finance and Audit, Leadership Development, and Public Policy and Advocacy committees, an Awards subcommittee, or the Reference Committee are encouraged to let APTA know of their willingness to participate. Application deadline is March 1.

    APTA heavily relies on its volunteers and needs the best skills, passion, and varied perspectives to build an energetic, inclusive, and innovative corps of volunteer leaders.

    Ready to take a lead in shaping the future of APTA? Apply through the Volunteer Interest Pool by updating your profile, then click "Apply for Current Vacancies" to answer questions specific to the committee. Don’t forget to click “Save Changes” to complete your application. Your profile and thoughtful responses to the application question will be read carefully and will help us select the most appropriate, diverse, and inclusive teams possible. For more information, contact Appointed Group Pool.

    PT, PTA Education Leadership Institute Accepting Applications for a Program That Inspires, Empowers, and Connects

    Being a director for a physical therapist (PT) or physical therapist assistant (PTA) education program can seem as lonely as it is overwhelming—but it doesn't have to be that way. Again in 2018, APTA is inviting a select group of emerging program directors to learn from mentors and each other in ways that will enhance their own work and strengthen the profession overall.

    The yearlong Education Leadership Institute (ELI) Fellowship program uses a blended learning approach (online and onsite components) to help PT and PTA educators in academic, residency, and fellowship settings to hone their skills in facilitating change, thinking strategically, and engaging in public discourse to advance the physical therapy profession. APTA is accepting applications to the program through March 1, 5:00 pm ET.

    ELI is a collaborative effort of the American Council of Academic Physical Therapy, Education Section, Physical Therapist Assistant Educators Special Interest Group, and APTA. It is accredited by the American Board of Physical Therapy Residency and Fellowship Education.

    Considering the fellowship experience? Check out the video testimonials of ELI graduates.