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  • The 2019 Fee Schedule, Part 1: 5 Things You Need to Know About What MIPS Might Look Like for PTs Next Year

    Part 1 of a 3-part series on the proposed 2019 Medicare physician fee schedule. This installment: how the Merit-based Incentive Payment System (MIPS) would play out for PTs and PTAs under the proposal.

    Beginning in 2019, physical therapists (PTs) and physical therapist assistants (PTAs) could be facing one of the most dramatic shifts toward value-based payment in Medicare, all courtesy of the US Centers for Medicare and Medicaid Services (CMS) and its proposed 2019 physician fee schedule. The biggest change: a requirement that eligible PTs participate in the CMS Quality Payment Program, where MIPS looms large.

    What is MIPS? Basically it's a reporting system that tracks 4 provider performance categories and awards performance points to produce a total annual MIPS score. That score in turn determines whether the providers earn a payment incentive, remain neutral in payment, or are subject to a penalty. Physicians and a few other providers have been participating in MIPS for the past 3 years at better-than-expected rates—now PTs, occupational therapists, social workers, and clinical psychologists may be added to the list of MIPS reporters. (Editor's note: this article from a 2017 issue of PT in Motion magazine lays out the fundamentals of the program; in addition, earlier this year the association produced a podcast series on value-based care that covers MIPS and other issues.)

    With the publication of its proposed 2019 physician fee schedule, CMS provided the first glimpse at how the system would be rolled out and applied to PTs. Here are 5 things to know about what CMS is proposing:

    1. Initially, PTs will be assessed on only 2 of the 4 MIPS categories.
    Although physicians participating in MIPS must report on all 4 MIPS categories—quality, promoting interoperability, clinical improvement activities, and cost—PTs will be assessed only on quality and clinical improvement activities, at least in 2019. The cost and interoperability categories will be "zero-weighted," according to the proposed rule.

    2. There are criteria for mandatory participation, and not all PTs or practices will qualify.
    MIPS has a so-called "low-volume threshold" that essentially exempts providers from reporting unless they meet 3 annual criteria: allowed charges under Medicare Part B for professional services of $90,000 or more; more than 200 Medicare Part B-enrolled individuals provided covered professional services; and more than 200 covered professional services provided to Part B enrollees. Remember, all 3 elements must be met: given that most PTs in private practice provide more than 200 covered professional services in a year, mandatory participation in MIPS will probably boil down to the total charges and patient numbers criteria.

    3. MIPS applies to PTs in private practice only—and group practices are assessed as a whole.
    For now, MIPS will be limited to PTs in a private practice, but it's important to understand that, unlike the physician quality reporting system (PQRS) that MIPS replaces, group practices will also be assessed for reporting as a whole. That means even PTs in group practices who do not exceed the low-volume threshold level as an individual provider will be required to participate at the group level if the group itself is participating in MIPS and, combined, exceeds the low-volume threshold.

    4. You could still participate in MIPS voluntarily (and it may be a good way to understand the system before you're required to report).
    Beginning in 2019, PTs will have 2 ways to participate in MIPS by choice. First, those who meet 1 or 2 of the 3 participation criteria listed in tip 2 will be allowed to opt in to MIPS. Providers who choose to opt in would do so on an annual basis, and once they make that election they would be treated like a MIPS participant, with the ability to earn a payment incentive, remain neutral in payment, or receive a penalty based on their performance. Second, as in previous years, voluntary participation in MIPS by PTs who aren't required to do so would remain an option, with no payment adjustments associated with participation. APTA encourages voluntary participation in MIPS as a good way to get familiar with a system that seems likely to grow in its reach.

    5. Practices of more than 15 eligible clinicians would need to report to MIPS electronically beginning in 2019.
    Claims-based reporting would be limited under MIPS. Instead, electronic reporting via certified electronic health records (EHRs) or registries would be mandated for practices of 15 or more clinicians (not 15 or more PTs, but all MIPS-eligible providers in the practice). Claims-based reporting would still be an option for solo practitioners and smaller practices, but, again, it's important to understand that mandated electronic reporting is likely to be extended to ever-smaller practices in the coming years, so any providers not yet required to report electronically would be well-advised to start learning about and investing in technology now. APTA is helping to make MIPS reporting easier through its Physical Therapy Outcomes Registry, which has been recognized by CMS as a qualified path for electronic reporting.

    Up next in the series: it's not just about MIPS—a look at other ways PTs could participate in the CMS Quality Payment Program.

    Get ready for the future of PT payment: APTA offers a wide range of online resources on value-based care in general and MIPS in particular, including a readiness self-assessment quiz, a podcast series, a video, and more. Additionally, APTA's Physical Therapy Outcomes Registry has earned "qualified clinical data registry" status from CMS, meaning that PTs who participate in MIPS can use the PTOR to submit their data to CMS.

    The 2019 Fee Schedule, Part 2: Quality Reporting Options Other Than MIPS

    Part 2 of a 3-part series on the proposed 2019 Medicare physician fee schedule. This installment looks at alternatives to participation in the Merit-based Incentive Payment System (MIPS).

    For physical therapists (PTs), required participation in MIPS seems like the big news in the US Centers for Medicare and Medicaid Services (CMS's) proposed 2019 physician fee schedule. And it is big news—but it's just a part of an even bigger picture known as the Quality Payment Program (QPP), the real heavyweight in the proposed rule.

    It's actually QPP that PTs, occupational therapists, social workers, and clinical psychologists would be required to participate in beginning in 2019. MIPS is just 1 way of doing it (part 1 of this series covered some of the must-knows about how that system works). But CMS also proposes other ways that PTs might participate, mostly by way of Advanced Alternative Payment Models (AAPMs) or through an option that involves a Medicare Advantage demonstration.

    So what should you consider when weighing the non-MIPS alternatives for participating in QPP? Here are a few basic concepts to keep in mind.

    Don't get overwhelmed. AAPMs are complicated—but they're not impossible to understand.
    First, about AAPMS: they are a subset of alternative payment models (APMs). To quality as an AAPM, according to the proposed fee schedule, the model must meet the following 3 criteria:

    • Require at least 75% of all eligible clinicians to use certified electronic health record technology (CEHRT) in 2019 for all CMS-created APMs, and by 2020 for so-called "other payer" APMs
    • Use quality measures that are comparable to those used in MIPS
    • Put some skin in the game by bearing financial risk for underachieving—CMS is proposing that the risk would need to be equal to 8% of the average estimated total Medicare Parts A and B revenues of providers and suppliers in the APM, or 3% of the expected expenditures that an APM entity is responsible for under the APM

    Under the proposed rule, PTs who fully participate in an AAPM—that is, PTs who meet or exceed the relevant payment amount or patient count threshold for the year based on participation in an AAPM to become Qualifying APM Participants (QPs)—would not be required to comply with MIPS and would be eligible for payment adjustments (depending on the AAPM’s payment arrangement) as well as a 5% Medicare bonus

    There are 2 kinds of AAPMs to choose from.
    In the proposed rule, there are 2 varieties of AAPMs that would be open to PT participation: "Medicare Option" AAPMs and "All-Payer Combination Option" AAPMs.

    The Medicare Option path proposed for 2019 includes CMS-created models such as the Comprehensive Care for Joint Replacement Model (but only the CEHRT track), the Next Generation ACO Model, the Medicare ACO Track 1+, and others. To get a better idea of this grouping, check out the current list of Medicare AAPMs on the CMS website.

    For payment years 2021 and later, eligible clinicians may become QPs through a combination of participation in Medicare AAPMs and Other Payer AAPMs—a so-called "All-Payer Combination Option." This path allows providers to take a hybrid approach by participating in both a Medicare AAPM(s) and a CMS-approved AAPM(s) provided by Medicaid and other payers. Under this option, QPs are assessed by CMS through participation in both AAPMs.

    The real question: would you qualify?
    The AAPM-based QPP option allows participants to be exempted from MIPS and opens up the possibility of a 5% annual payment bonus (beginning in 2021 for the 2019 performance year) in addition to payment adjustments up or down; however, certain patient or payment thresholds must be met.

    What are the thresholds? Again, it depends on which AAPM path you're pursuing. For payment year 2021 (performance year 2019), in order to be considered a QP in the Medicare Option path, you must have provided services through Medicare AAPM(s) for at least 35% of your Medicare Part B patients or have earned at least 50% of all Medicare Part B payments through the AAPM(s).

    The All-Payer Combination is a little more complicated because it involves quotas for both Medicare and total payments and patients: at least 25% of Medicare Part B payments and at least 50% of all payments through AAPMs, and at least 20% of Medicare Part B patients and at least 35% of all patients served by way of the AAPMs.

    It's also possible that if you don't meet these thresholds, you can participate via a "partial QP threshold" option, with lower payment and patient thresholds. Partial QP participants are not subject to the MIPS reporting requirements and payment adjustments unless they choose to report to MIPS, but they do not qualify for the 5% bonus.

    CMS has proposed a possible QPP participation option based on Medicare Advantage.
    It's called the Medicare Advantage Qualifying Payment Arrangement Demonstration (MAQI), and under the proposed fee schedule, it would work like this: providers who participate "to a sufficient degree" with a qualifying payment arrangement through a Medicare Advantage organization could be exempted from MIPS reporting and payment adjustments. Providers also wouldn't be required to meet the QP thresholds associated with the AAPM options, but they would need to apply for the demonstration project in advance. CMS has issued a fact sheet that goes into more detail on the plan.

    Part 3 of the series: beyond QPP—the end of functional limitation reporting, future coding changes that could affect physical therapist assistant payment, and a telehealth shift.

    Get ready for the future of payment: APTA offers a wide range of online resources on value-based care, including a readiness self-assessment quiz, a podcast series, a video, and more. Additionally, APTA's Physical Therapy Outcomes Registry has earned "qualified clinical data registry" status from CMS, meaning that PTs who participate in MIPS can use the PTOR to submit their data to CMS.

    The 2019 Fee Schedule, Part 3: The End of FLR, the Move to PTA-Specific Codes, and a Nod to Technology

    Part 3 of a 3-part series on the proposed 2019 Medicare physician fee schedule. This installment: there's more to the proposed rule than PTs being required to participate in the Quality Payment Program—including some very good news.

    The fact that physical therapists (PTs) could be widely engaged in a value-based payment model in 2019 is definitely the big takeaway from the proposed 2019 physician fee schedule released by the US Centers for Medicare and Medicaid Services. But the sweeping proposal also includes some other significant changes that could affect both PTs and physical therapist assistants (PTAs). Here's a rundown of 3 of the biggest non-Quality Payment Program-related changes included in the proposed rule.

    Something to celebrate: the end of functional limitation reporting (FLR).
    Criticized by APTA as an undue administrative burden that yields little of value, FLR would finally be put out to pasture if the proposed rule is adopted. In its reasons for eliminating the requirement, CMS described the "general consensus" of commenters responding to a CMS request for ways to reduce administrative burden that FLR was "overly complex and burdensome." The agency estimates that PTs in private practice would have saved between 130,000 and 190,000 hours of administrative work in 2017 had FLR not been in place.

    The change is a win for APTA and its members, and the association is mentioned in the proposed rule as a "specialty society" that supplied CMS with data on the inconsistent timing of FLR reporting—another issue that fueled the decision to eliminate the requirement.

    Something to be concerned about: is CMS setting the stage for the PTA payment differential?
    If enacted as proposed, the rule would establish 2 new therapy modifiers to identify the services furnished in whole or in part by PTAs or occupational therapy assistants (OTAs) beginning. January 1, 2020. The modifiers, mandated by the Bipartisan Budget Act of 2018, would be used in place of the GP and GO modifiers—the ones currently used to identify PT and OT services furnished under an outpatient plan of care—and will pave the way for a planned payment differential that would reimburse services provided by PTAs and OTAs at 85% of the fee schedule beginning in 2022.

    Although the modifiers won't officially be in place until 2020, CMS plans on accepting voluntary use of the modifiers next year. CMS also proposes to define “in part” to mean any minute of the outpatient therapy service that is therapeutic in nature and that is provided by the PTA or OTA when acting as an extension of the therapist. The new modifiers would not be applied when a PTA or OTA furnishes non-therapeutic services—such as scheduling appointments, greeting the patient, or preparing the treatment area.

    APTA is opposed to the adoption of a payment differential system and will be advocating for changes before the 2022 implementation date.

    Something to keep an eye on: CMS may be warming up to broader use of technology.
    While it appears that, for now at least, the changes will be limited to physicians and other qualified health professionals who can report evaluation and monitoring services, CMS is proposing that activities such as virtual check-ins, interprofessional internet consultation, and remote evaluation of prerecorded patient information could qualify for some form of payment. APTA is seeking clarification from CMS as to whether any of these services could be furnished and billed by PTs.

    Get ready for the future of PT payment: APTA offers a wide range of online resources on value-based care, including a readiness self-assessment quiz, a podcast series, a video, and more. Additionally, APTA's Physical Therapy Outcomes Registry has earned "qualified clinical data registry" status from CMS, meaning that PTs who participate in MIPS can use the Registry to submit their data to CMS.

    APTA Offers Help With Payment Denials

    Putting together an appeal of a denied claim isn't anyone's idea of a good time, but at least APTA is making the process a little easier.

    Now available to APTA members: customizable template letters that help make the case for payment. The letters target 3 types of denials:

    Denials related to change in practice location. This letter is crafted to address a Medicare Administrative Contractor's (MAC) denial of payment based on an erroneous conclusion that the provider didn't give sufficient notice of a change in practice location.

    Denials related to the use of the 59 modifier. The template, applicable to both MAC and private insurer denials, helps make the case for valid use of the 59 modifier, used to represent a service that is separate and distinct from another service it's paired with.

    Denials related to medical necessity. Also usable in both Medicare and private insurance-related appeals, this letter helps a member articulate why services were in fact medically necessary.

    The templates, offered in Word, include directions for inserting crucial patient and treatment details to strengthen the appeal argument. All 3 letters are available on APTA's Medicare Denials, Audits, and Appeals webpage; the 2 letters applicable to private insurers also can be found on the association's Commercial Insurance webpage, along with a general appeal letter outline.

    APTA will post more templated appeal letters in the coming months, so be sure to check back.