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  • New Targeted Manual Medical Review System: 6 Things You Should Know

    The much-anticipated changes to the way the Centers for Medicare and Medicaid Services (CMS) conducts its manual medical reviews (MMRs) are under way, with the first round of requests for additional documentation (ADRs) now being sent to providers (here's a sample ADR).

    Here's what you need to know:

    1. The new system targets behaviors.
    The old MMR system was automatically triggered when a provider exceeded the $3,700 mark. The new one does not require MMRs for all claims exceeding the threshold, and instead takes a targeted approach, looking at providers who have provided a high amount of hours or minutes of therapy to patients in a single day.

    2. The reviews fall into 3 practice setting buckets: skilled nursing facilities (SNFs), private practice, and outpatient facilities.
    Home health part B claims aren't a part of the review process.

    3. ADRs will be limited to 40 claims per provider.
    Each claim will be reviewed; some may be upheld and others denied.

    4. The review contractor has 45 days to respond with its decision.
    CMS has contracted with Strategic Health Solutions (SHS) to serve as the supplemental medical review contractor (SMRC). This is who you'll be dealing with initially should you receive an ADR. Once you submit your information, the SMRC has 45 days to get back to you with a decision. After that, the SMRC will take no further action—though it can turn things over to the Medicare administrative contractor for further review.

    5. A "discussion period" allows you to fix errors or add information to the files you submitted.
    Making these changes could help you undo a denial. The discussion period is roughly 30 days, but you must request it.

    6. The process includes comparison with peers.
    Part of SHS's process for determining whether a billing process is potentially aberrant involves comparing providers who are doing the same thing—PTs in private practice, for example.

    The targeted MMR process is part of a wave of changes associated with the Medicare and CHIP Reauthorization Act (MACRA), a sweeping law that addresses payment issues in the aftermath of the repeal of the sustainable growth rate (SGR). APTA is developing a series of fact sheets on MACRA and will continue to monitor the new MMR process and provide updates as more information becomes available.

    CMS Offers Training on Coming IRF Changes

    Changes to reporting requirements for inpatient rehabilitation facilities (IRFs) are coming this fall, and the Centers for Medicare and Medicaid Services (CMS) is helping providers prepare.

    Now available for free download from CMS: presentation slides from a recent 2-day workshop that explored the ways that reporting on everything from functional abilities to falls will change under rules that implement portions of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. That law, passed in 2014 and supported by APTA, seeks to standardize data collected across postacute health care settings. The new reporting requirements begin October 1, 2016.

    Originally presented as a "train-the-trainer" event in mid-May, the meeting's agenda and all slides can be found by scrolling down the CMS IRF Quality Reporting Training webpage to the Downloads section. The compressed files, all pdf versions of PowerPoint slides, are labelled "IRF Training" 1, 2, and 3. Recordings of the training sessions will be posted to the CMS YouTube site in several weeks.

    Topics include an overview of the changes and more detailed information on reporting requirements around functional abilities and goals; falls; swallowing and nutritional status; skin conditions; hearing, speech, and vision; bladder and bowel; cognitive patterns; and special treatments, procedures, and programs. Slides also cover active diagnoses, and IRF-PAI (patient assessment instrument) data submission and Certification and Survey Provider Enhanced Reports (CASPER).

    Innovation 2.0 Series of Learning Labs Kicks Off With Pay for Performance

    Insights on developing and implementing a pay-for-performance program that focuses on delivering care for patients with low back pain are yours to glean from the first Innovation 2.0 Learning Lab, now available in the APTA Learning Center. This free webinar includes the recorded session, including the presenters’ slide deck, and a downloadable guide to replicating the program in other practices.

    The inaugural online Learning Lab in APTA’s Innovation 2.0 series focuses on a pay-for-quality program for treatment of patients with low back pain (LBP). The project, conducted through Intermountain Healthcare in Salt Lake City, Utah, focuses on LBP treatment as the basis for a comprehensive incentive program that doesn't just tally outcomes but looks at what prevents some patients from progressing. The project includes development of a "severity adjustment formula" that could predict when a patient has a low chance of achieving a minimally clinically important difference from physical therapy—before physical therapy begins.

    The Innovation 2.0 series is designed to promote the participation of physical therapists in innovative models of care delivery by replicating successful models throughout the country. Free access to the course and materials is available through the APTA Learning Center.

    Look for other Innovation 2.0 Learning Labs later this year; topics include adding value to a postacute care setting, PTs as part of an accountable care organization, and a patient-centered medical home model that addresses childhood obesity.

    New MACRA Systems Could Affect PTs by 2019: Here Are 5 Things You Need to Know Now

    Physical therapists (PTs) may not be immediately affected, but make no mistake: the future of payment has arrived. And it's time to start preparing.

    Last week, the Centers for Medicare and Medicaid Services (CMS) released proposed new rules for the Medicare and CHIP Reauthorization Act (MACRA). As promised, the new rules feature some game-changers for health care providers around the CMS Quality Payment Program, specifically through the Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs).

    Although PTs will not be included when the new systems begin in 2017, APTA Director of Regulatory Affairs Roshunda Drummond–Dye says that members of the profession can be assured that it's only a matter of time. "It's clear that CMS hasn't forgotten physical therapy," she said. "MACRA is the first tangible step toward mandating a payment system that bases reimbursement on quality of care and outcomes and begins the phase-out of fee-for-service, and PTs need to familiarize themselves so they're not taken by surprise when the change reaches them, possibly as early as 2019."

    The proposed MIPS rule for next year affects physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and groups that include those providers. Among other things, the new system consolidates the Physician Quality Reporting Program (PQRS), the Value-Based Modifier Program (VBM), and the "meaningful use" of electronic health records (EHR) program into a single system that will rate providers according to 4 "performance categories": quality of care, advancing care information, clinical practice improvement activities, and cost/resource use.

    At the same time, CMS will get much more specific about requirements for approved APMs, and create a roadmap that will guide providers on forming or participating in models such as accountable care organizations and patient-centered medical homes. (For a useful overview of the MACRA changes, check out this recent article in Health Affairs. CMS has also provided an overview of MACRA and the proposed changes.)

    So what are the big takeaways for PTs right now? Here are 5 things you need to understand.

    1. Data collection systems such as the Physical Therapy Outcomes Registry will play a huge role.
      Although claims-based reporting is initially allowed under MIPS, the rule creates an infrastructure that will make participation in registries essential over the coming years, and by the time PTs enter MIPS, participation in a registry will mostly likely be mandated. "We've been saying for some time now that the collection and assessment of outcomes data is critical for PTs," Drummond-Dye said. "MACRA will only increase the importance."
    2. You need to get up to speed with EHRs.
      The "advancing care information" performance category is the rating category that contains evaluations of meaningful use of EHRs. So far, the meaningful use program hasn't directly affected PTs, but this too will change. The proposed rule under MIPS also factors in the use of a certified EHR, and that's not going away. "PTs will need to get serious about using an EHR if they haven't already done so," Drummond-Dye said.
    3. You can take MIPS for a test drive.
      While PTs aren't included in the list of providers who will be required to participate in MIPS beginning in 2017, it's possible to sign up for voluntary reporting to get a feel for the system before it becomes mandatory. Voluntary reporting is a good idea, not just for the individual PT, but as a way to assess MACRA's fit for the profession, and to guide advocacy around making the policy changes necessary to ensure that PTs can be successful in MIPS when it becomes a requirement.
    4. MIPS may be getting the most attention, but the APM changes are a big deal too—and the profession needs to be proactive about helping to shape future models.
      The ability to become a key player in an APM will be essential in future payment policy. The current scope of APMs in the rule is relatively narrow, but that scope will grow over time, and physical therapy will need to be at the table as the rule is widened. "It's APTA’s hope that there will be the opportunity to work with the federal government to create new APMs that will bolster participation," Drummond-Dye said. "The bottom line is, APTA and the profession have a lot of work to do in this area."
    5. We're not just talking Medicare.
      The policies contained in the MACRA proposed rule will not only affect Medicare payment but also sets forth payment polices that will extend to commercial payers. In other words: once MACRA starts affecting PTs, those effects will be felt nearly everywhere.

    APTA is developing a series of fact sheets on MACRA and will offer a comprehensive plan to help PTs participate in the voluntary report program in MIPS. In the meantime, programs such as APTA's Innovation 2.0 initiative are helping to better acquaint the profession with alternative payment models that include significant involvement from PTs.

    Court Dismisses Lawsuit Filed by NC Acupuncture Licensing Board

    Advocates for North Carolina physical therapists (PTs) have scored a victory by way of a superior court, which dismissed a lawsuit brought by the North Carolina Acupuncture Licensing Board (NCALB) against the North Carolina Board of Physical Therapy Examiners (NCBPTE), several PTs, and a physical therapy practice over the issue of dry needling by PTs.

    In September 2015, NCALB filed the lawsuit against NCBPTE, asking the Wake County Superior Court to declare that dry needling by PTs is the unlawful practice of acupuncture, and to require NCBPTE to advise its licensees that dry needling is outside the scope of physical therapist practice. The acupuncture board also asked the court authorize it to send cease and desist letters to PTs who practice dry needling and to sue the PTs who refuse to comply.

    On April 26, Judge Louis Bledsoe III dismissed the suit largely on jurisdictional grounds. "There is no reason to stop North Carolina patients from receiving dry-needling treatment," said North Carolina Physical Therapy Association (NCPTA) President C. David Edwards, PT, DPT, CCCE, in a statement posted to the NCPTA website. "This is especially true when the ones who are trying to eliminate dry needling are doing it to protect their power in the marketplace."

    The dismissal of NCALB’s case against the PT board is not the end of the fight over dry needling in the state. A second lawsuit filed in early October challenging NCALB’s efforts to prevent PTs from engaging in dry needling is still pending in US District Court. That lawsuit, supported by NCPTA, argues that NCALB is violating antitrust law and due process rights in its actions to prevent PTs from practicing the skilled intervention.

    The plaintiffs in the case, titled Henry v North Carolina Acupuncture Licensing Board, filed their lawsuit against NCALB after several years of efforts by the acupuncture board to shut down dry needling by physical therapists. NCALB engaged in various actions to prevent PTs from performing dry needling, including the issuing of "cease and desist" letters to PTs and clinics across the state claiming that the PTs practicing dry needling were illegally engaged in the practice of acupuncture, a Class 1 misdemeanor.

    The Henry lawsuit has legal support in a 2015 decision by the US Supreme Court holding that state licensing boards controlled by market participants, such as NCALB, are not exempt from antitrust claims unless their conduct is actively supervised by the state. The NCPTA lawsuit is the first in the country to bring this type of antitrust violation claim on behalf of PTs since the Supreme Court decision.

    NCPTA set up a "Go Fund Me" page to help fundraising efforts. APTA is working collaboratively with the chapter, and is providing support as NCPTA pursues the legal action.

    Dry needling has been discussed in several states, most of which have included the intervention as part of the PT scope of practice. APTA has created a webpage with resources on the topic, and the association's Learning Center offers courses on dry needling and clinical decision-making and background evidence for dry needling.

    Bill to End Physician Self-Referral Reintroduced in the House

    Welcome back: APTA and a coalition of medical groups are applauding the reintroduction of a bill in the House of Representatives that would close up Medicare self-referral loopholes. Those loopholes allow physicians to refer patients for certain services—including physical therapy—to a business that has a financial relationship with the referring provider.

    Titled the Promoting Integrity in Medicare Act (PIMA), the bill seeks to eliminate exceptions to the federal law originally intended to prohibit self-referral. That law, known as the Stark law, does prohibit most self-referral practices, but it also contains language that allows physicians to self-refer for several "common sense" or same-day treatments. Unfortunately those exceptions also include services that are rarely provided on the same day—physical therapy, anatomic pathology, advanced imaging, and radiation therapy.

    PIMA would eliminate those loopholes not only as a way to ensure that the exceptions are used according to their original intent, but to reduce overutilization and overall health care costs. According to the latest estimates from the Congressional Budget Office, enacting the changes contained in PIMA would save Medicare an estimated $3.3 billion over 10 years, mostly due to what research points to as overuse of referrals among providers who can direct patients to services with a financial connection. The bill is sponsored by Rep Jackie Speier (D-CA14), who introduced a similar bill in 2014.

    "How many [Government Accountability Office] studies outlining the abuse and billions of dollars of Medicare reimbursement to doctors for unnecessary services that are driven purely for personal profit does it take to shut this activity down?" said Speier in a statement on the bill. "This is a golden opportunity to put patient health and program health over profits. We should always work to improve the quality and cost-effectiveness of government programs—this bill will save taxpayers money and help seniors who depend on Medicare for their quality of life."

    APTA is a strong supporter of the legislation, and is a member of the Alliance for Integrity in Medicare (AIM), a coalition of professional groups opposed to their services' inclusion in the Stark exceptions. AIM isn't alone in the fight: in 2014, the American Association of Retired Persons (AARP) issued a statement in support of PIMA.

    "The exceptions in the Stark law were intended to allow a limited number of common services such as lab tests and x-rays to be performed during office visits," said Michael Hurlbut, APTA senior congressional affairs specialist. "PIMA doesn't change that, but it does remove physical therapy from a list of exceptions that it should never been a part of in the first place."

    "Reforming the … exception through the passage of [PIMA] will ensure Medicare recipients receive the highest quality and safest health care appropriate to their needs," AIM says in a statement on the bill, adding that the estimated savings "is in the best interests of beneficiaries, providers, and our nation's health care system overall."

    Find out more about this issue on APTA's self-referral webpage, and take action now by asking your legislators to close the self-referral loophole. Contact the APTA advocacy staff for more information.

    APTA-Supported Youth Sports Opioid Education Bill Moves Ahead

    A bill supported by APTA that recently passed US House of Representatives Energy and Commerce Committee could help to bring needed education on the dangers of opioids—and the benefits of alternative, nonopioid approaches to pain treatment, such as physical therapy—to youth sports.

    On April 27, the committee reviewed the John Thomas Decker Act (H.R. 4969), proposed legislation that would direct the Centers for Disease Control and Prevention (CDC) to develop and provide educational materials specifically targeted at teenagers who have been injured playing youth sports. The bill is sponsored by Republican Reps Patrick Meehan (PA-7) and Thomas Rooney (FL-17), and Democrats Ron Kind (WI-3) and Marc Veasey (TX-33).

    "APTA believes it is crucial to provide teenagers and adolescents injured in sports with appropriate educational materials related to the costly and addictive nature of opioids and to safe and effective treatment alternatives, such as physical therapy," stated APTA President Sharon L. Dunn, PT, PhD, OCS, in an APTA letter in support of the bill. "The John Thomas Decker Act will play a critical role in helping to curb this epidemic [of opioid abuse and heroin use] by ensuring adequate knowledge for our nation's youth."

    The CDC is well-positioned to provide education that supports alternatives to opioids for pain, having issued a set of high-profile prescription guidelines that cite nonopioid approaches, including physical therapy, as the recommended first-line treatment.

    The bill was forwarded to the House for a full vote.

    New Wisconsin Law Allows PTs to Order X-Rays

    Physical therapists (PTs) in Wisconsin now have a big addition to their licensing law: the ability to order x-rays. The change, signed into law by Gov Scott Walker on April 25, marks the first time any state has specifically authorized PTs to make the decision.

    Under the new law, to be able to order x-ray imaging, the PT must hold a clinical doctorate degree or a specialist certification, or have completed a board-approved residency or fellowship, or a formal X-ray ordering training "with demonstrated physician involvement."

    The law also requires the PT to communicate the x-ray order to the patient's primary care physician "or an appropriate health care practitioner" to ensure coordination of care. That communication is not required if the patient doesn't have a primary care physician or was not referred to the PT by another practitioner, or if the radiologist doesn't identify a significant finding.

    According to Angela Shuman, APTA's director of state government affairs, the Wisconsin law is historic because it's the first time a state PT licensing law has specifically listed ordering x-rays as within a PT's scope of practice.

    "No other state PT practice acts specifically say that PTs can order x-rays—the laws are mostly silent on the matter," Shuman said. "This lack of specific language can make it difficult for PTs to understand just what they can or can't do, but Wisconsin has taken the step to make things very clear." The state has also changed the licensing law for the individuals who perform radiologic procedures such as x-rays, specifying that they can now accept orders from licensed PTs, she explained.

    APTA, the Wisconsin Physical Therapy Association, and supporters worked for more than 2 years to advocate for the new law.

    The bill was sponsored by Rep Joe Sanfelippo in the Wisconsin State Assembly, with a companion bill in the state senate sponsored by Sen Van Wanggaard. The bill becomes effective the day after it is electronically published by the state's Legislative Reference Bureau.

    SNF and IRF Proposed Rules Continue CMS Push Toward Quality Reporting, Value-Based Payment

    Continued emphases on quality reporting and new payment models are at the center of the Centers for Medicare and Medicaid Services’ (CMS) proposed 2017 rules for skilled nursing facilities (SNFs) and inpatient rehabilitation facilities (IRFs), along with an $800 million increase in payments to SNFs, and a $125 million increase for IRFs.

    CMS is proposing an overall payment increase of 2.1%, or an estimated $800 million, but the rule also includes notice that CMS is continuing its push for quality-reporting measures required by the Improving Post Acute Care Transformation (IMPACT) Act. The 2017 proposed rule adds to the list of quality measures that will be required of SNFs beginning in 2018 to include data on discharge to community, Medicare spending per beneficiary, and potentially preventable 30-day readmissions. The proposal also stipulates that by 2020, SNFs will be required to supply reports on drug regimen reviews with follow-up.

    The rule also provides a few more details on how CMS intends to create a value-based purchasing program (VBP) for SNFs as it continues to research different models. According to a fact sheet from CMS, the agency will seek public comment on performance standards, performance periods, scoring methodology, and the development of confidential feedback reports. APTA will advocate for a physical therapy representative to serve on the technical expert panel that will review input.

    Next year's payment increase for IRFs is proposed to drop slightly from this year's overall 1.6% increase, down to 1.45% overall (estimated $125 million), though the final amount may be updated "if more data becomes available," according to a CMS fact sheet.

    Like the SNF proposed rule, the IRF proposal also establishes more quality-reporting requirements around many of the same areas that will be required of SNFs (discharge, spending, readmissions, drug regimen review, etc). Additionally, the IRF rule would add 4 new measures to the facilities' public reporting requirements, including reports to a publicly accessible CMS website, such as Hospital Compare.

    APTA will submit comments on both proposed rules by the June 20 deadline. In addition, the association will develop fact sheets on the rules to help members understand what's being proposed.

    Inpatient Payment Proposed Rule Eliminates '2 Midnight' Reductions, Delivers 1-Time Increase to Hospitals

    The Centers for Medicare and Medicaid (CMS) will not only back away from payment cuts associated with the "2 midnight" rule in 2017, but will actually award hospitals a .6% increase, according to a proposed inpatient prospective payment system (IPPS) and long- term care hospital rule released recently. In addition to the shift away from the penalties, the proposed rule continues the agency's push for more quality reporting and value-based purchasing.

    The biggest news from the proposed rule is that CMS will not implement a .2% reduction for inpatient services—a cut designed to offset what it had anticipated would be increased spending associated with the 2-midnight rule. The 2-midnight rule was intended to reduce costly admissions in cases better suited to outpatient treatment by stipulating that auditors can presume that an admission is reasonable and necessary if the patient spent at least 2 days as an inpatient, defined as 2 midnights in a hospital bed.

    The rule was challenged in a lawsuit filed by the American Hospital Association (AHA) and other groups. In September, a judge partially sided with the AHA and ordered the US Department of Health and Human Services to justify the cut. While CMS maintains that the assumptions it used to establish the cut were reasonable, it has announced in a fact sheet that the penalty will be permanently removed "in light of recent review and the unique circumstances."

    Additionally, to account for the effects of the penalty in the years since the rule's adoption in 2013, CMS has announced that hospitals will receive a 1-time .6% increase in 2017. According to an article in Modern Healthcare, the combined effects of the adjustment and other additional payments in the rule amount to a $539 increase for the IPPS.

    Other notable provisions in the new rule:

    • CMS will implement a standardized process for ensuring that Medicare beneficiaries who have been receiving outpatient observation status for more than 24 hours are well-informed of how observation status affects cost-sharing and eligibility for Medicare coverage of skilled nursing facility services. A form, called MOON (Medicare Outpatient Observation Notice), must be accompanied by an oral explanation. The patient (or designee) must also sign the MOON to verify that he or she understands the implications of observation status.
    • The Value-Based Purchasing Program will expand to include not only more units but more measures used to evaluate those units—over time. The additional units won't be added until 2019, and the additional measures—which include 30-day pneumonia mortality, acute myocardial infarction, heart failure, and coronary artery bypass grafting mortality rates—will be added in 2021 and 2022.
    • In order to satisfy the requirements of the Improving Post-Acute Care Transformation (IMPACT) Act, CMS is proposing 3 claims-based measures and 1 new assessment-based quality measure to be included in the LTCH quality reporting program (QRP). The 3 claims based measures are discharge to community, Medicare spending per beneficiary, and the potentially preventable 30-day post-discharge readmission measure. The assessment-based measure being added is a drug regimen review conducted with follow-up for identified issues.

    APTA regulatory affairs staff will continue to monitor the proposed rule, and will make a fact sheet available in the coming weeks.

    For more on how the shift in models of care affects physical therapy, don't miss the NEXT Conference and Exposition, June 8-11 in Nashville, and check out "Maximizing Physical Therapy's Value: How to Best Transition to Value-Based Care."