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  • IRFs Could See 2.5% Increase From CMS in FY 2020; Additional Reporting Requirements in FY 2022

    If a proposed rule from the US Centers for Medicare and Medicaid (CMS) is adopted as planned, inpatient rehabilitation facilities (IRFs) will see a 2.5% payment increase in the 2020 fiscal year (FY), which begins October 1, 2019—an approximate boost of $195 million. But they'll also need to prepare for some expanded reporting measures in the years to come—including a requirement to report data on social determinants of health (SDOH).

    Reporting requirements wouldn't change much in fiscal year (FY) 2020 (beginning October 1, 2019). However, beginning with the FY 2022 IRF Quality Reporting Program (QRP), IRFs would be required to provide certain standardized patient assessment data (SPADE) to CMS. The additional SPADE requirements are aimed at bringing IRFs up to speed with provisions of the 2014 IMPACT Act, a law that mandated more uniformity in reporting across postacute care (PAC) settings.

    Beginning in the 2022 fiscal year, IRFs would be required to report patient data on admissions and discharges dating back to October 1, 2020, in the following areas: cognitive function and mental status; special services, treatments, and interventions; medical conditions and comorbidity; impairment; and a new category—social determinants of health (SDOH). IRFs have been reporting on some components of these areas since 2018, mostly related to function, pressure wounds, and skin integrity.

    The new SDOH would gather data on race, ethnicity, preferred language, interpreter services, health literacy, transportation, and social isolation—factors that CMS writes "[have] been shown to impact care use, cost, and outcomes for Medicare beneficiaries."

    CMS also wants to introduce 2 new process measures; one having to do with whether a provider receives a current reconciled medication list at discharge or transfer, and another relating to whether the patient, family, or caregiver receives a similar list upon discharge from a PAC setting.

    Among other elements of the proposed rule:

    The compliant IRF list may go. CMS is proposing to stop publishing a list of compliant IRFs on the Inpatient Rehabilitation Facility Quality Reporting Program (IRF QRP) website.

    Reporting for some baseline nursing facility residents would decrease. Specifications of the discharge-to-community PAC measure would be altered to exclude baseline nursing facility residents.

    IRFs could make the call on who's considered a "rehabilitation physician." The proposed rule would loosen the definition of "rehabilitation physician," allowing individual IRFs to make the determination. At the same time, CMS is seeking comments on refining the definition in light of the proposed change.

    As is typical, CMS is also seeking input on several areas not related to specific impending rule changes for FY 2020, including stakeholder comments on pain interference on sleep, therapy activities, and day-to-day activities—provisions that CMS is considering adding in light of the opioid crisis. The agency also seeks general feedback on possible additional SPADE data elements including dementia, bladder and bowel continence, care preferences, advance care directives and goals of care, caregiver status, veteran status, health disparities and risk factors, and sexual orientation. Potential measures CMS would like feedback on include assessments related to opioid use, and frequency and exchange of electronic health data as well as interoperability.

    APTA will submit comments on the proposed rule by the June 17 deadline. To weigh in on the proposed rule, check out APTA's regulatory "Take Action" webpage in the coming days for information on how and where to submit comments.

    CMS Adds to DMEPOS Prior Authorization List

    Physical therapists (PTs) who are providers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) will see an expansion of the range devices that require prior authorization under Medicare, when the US Centers for Medicare and Medicaid Services (CMS) adds 12 more items to its list beginning July 22 of this year.

    Seven of the 12 new codes are related to power mobility devices, with the additional 5 related to pressure-reducing support surfaces. The additions follow last year's introduction of 31 DMEPOS items that CMS moved to a nationwide preauthorization system. Prior to that, the preauthorization policies for those devices were limited to a demonstration project in 18 states.

    CMS also added 4 new items to the master list of DMEPOS that are considered frequently subject to unnecessary use, including a particular back brace (L0650). CMS uses the master list to decide which items it will add to the prior authorization list.

    CMS offers a webpage focused on the DMEPOS prior authorization program and has published a notice and list of the 12 codes to be added. A full list of DMEPOS requiring prior authorization is also available from CMS. APTA offers more resources at its DMEPOS webpage as well as through a clinical mobility device documentation guide.

    CDC Reiterates Limits of Opioid Prescribing Guideline

    The US Centers for Disease Control and Prevention (CDC) wants to make it clear: its guideline on the use of opioids for the treatment of chronic pain is not intended to apply to pain related to cancer treatment, palliative care, or end-of-life care. The clarification is consistent with messaging used by APTA in its #ChoosePT opioid awareness campaign and its MoveForwardPT.com consumer-focused website.

    In a February 28, 2019, letter from CDC Chief Medical Officer Deborah Dowell, MD, MPH, the agency restates its intentions around the prescribing guideline, issued in 2016, that recommends nonopioid approaches including physical therapy as a preferred first-line treatment for some—but not all—types of chronic pain.

    "The Guideline was developed to provide recommendations for primary care physicians who prescribe opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care," Dowell writes. "Because of the unique therapeutic goals, and balance of risks and benefits with opioid therapy in such care, clinical practice guidelines specific to cancer treatment, palliative care, and end-of-life care should be used to guide treatment and reimbursement decisions regarding use of opioids as part of pain control in these circumstances."

    The letter was written in response to concerns voiced by the National Comprehensive Care Network, the American Society of Clinical Oncology, and the American Society of Hematology that some payers were balking on paying for opioid prescriptions in circumstances outside the scope of the CDC guidelines.

    Even without the clarification, the original guideline is explicit in its intent, which appears in the first sentence of the document and again when the CDC describes the scope of the guideline and intended audience. Similarly, APTA makes it clear that doctor-prescribed opioids are appropriate in some cases and has included that message in both its #ChoosePT webpage and its public service announcement related to the opioid crisis.

    "The Guideline is not intended to deny any patients who suffer with chronic pain from opioid therapy as an option for pain management," Dowell writes. "Rather, the Guideline is intended to ensure that clinicians and patients consider all safe and effective treatment options."

    President's Budget Proposes Cuts to Public Health Programs, Health Research, Medicare, and Medicaid

    Although characterized by supporters as an approach that "embodies fiscal responsibility," the 2020 federal budget proposal from the Trump administration is facing criticism that the $4.1 trillion plan cuts too deeply into health care and education. Many of the proposed changes run counter to current APTA public policy priorities by reducing access to care and sacrificing important investments in research and education.

    The proposed budget, released by the White House last week, was touted by acting Office of Management and Budget Director Russ Vought as a plan that "takes aim at Washington's fraud, waste, and abuse," and will lead to a balanced budget in 15 years.

    Others see things differently. The approach is accompanied by significant cuts to a range of issues important to APTA, including funding decreases for the National Institutes of Health, the Centers for Disease Control and Prevention, the Administration for Community Living, the National Health Services Corps, and the Maternal and Child Health Block Grant program. The budget also includes policy recommendations that alter Medicaid and Medicare.

    The budget proposal is just that—a proposal. Congress must act on the plan in order for it to become law. APTA Executive Vice President of Public Affairs Katy Neas says that while the budget itself isn't likely to survive, there's a danger that some of the more damaging concepts could live on.

    "It's unlikely that Congress will embrace the changes to Medicare, Medicaid, and funding for important work at the National Institutes of Health," Neas said. "However, the challenge for APTA, the physical therapy profession, and patients will be to keep up the pressure against some of the budget's more damaging ideas that may resurface from time to time in policy debates."

    Among those more damaging ideas, according to APTA: the administration's proposal to move Medicaid away from its current funding system to a per-capita block grant program. The administration estimates the change could result in a $160 billion savings, but critics say the shift would reduce access to care, as would another provision in the plan that would mandate work or community volunteer requirements for "able-bodied, working-age individuals."

    The plan also calls for cuts to Medicare, primarily through a combination of payment decreases, more stringent oversight of individual provider reimbursement patterns, and more extensive prior authorization requirements for physicians.

    Among the provisions of particular interest to physical therapists (PTs) and their patients and clients:

    • Durable medical equipment, prosthetics, and orthotics (DMEPOs). Under the Trump budget, the US Centers for Medicare and Medicaid Services (CMS) competitive bidding program would be extended to apply to ventilators and orthotics, which could interfere with patient access to these devices as well as the ability for patient-specific adjustments to be made by providers. Additionally, the proposal would expand CMS prior authorization authority to additional DMEPOs—another provision that APTA believes could delay or prevent patient access.

    • Postacute care payment. The proposed budget steadily lowers annual Medicare payment updates for skilled nursing facilities, home health agencies, and inpatient rehabilitation facilities beginning in the 2020 fiscal year, leading up to the adoption of a unified postacute payment system for all settings in the 2025 fiscal year.

    • Prior authorization authority. The budget extends CMS authority to require prior authorization for all Medicare fee-for-service items and services, specifically those that CMS claims are at high risk for fraud and abuse.

    • Oversight of "excessive" physician orders for certain services—including therapy. The administration budget seeks to establish a prior authorization program for high-utilization practitioners of radiation therapy, therapy services, advanced imaging, and anatomic pathology services beginning in 2021. CMS would conduct annual reevaluations to identify the physicians who would be subject to prior authorization in the next calendar year.

    • National Institutes of Health (NIH) funding. The proposal would lower NIH funding by $4.5 billion to $6 billion compared with 2018, including a $900 million reduction in funding for the National Cancer Institute.

    • Education. In addition to reducing funding for college work-study programs and ending loan forgiveness for public-sector workers, the administration's plan would cancel a $1.4 billion surplus in the federal Pell grant program.

    "APTA's advocacy focus is on increasing patient access to effective care, eliminating inefficiencies and reducing administrative burden on providers, and supporting research and innovation," Neas said. "The administration's 2020 budget in many ways stands in contrast to those priorities, and we will continue to help legislators and policymakers understand the important differences."

    Education Leadership Partnership Looks Back On a Productive Year

    When the purpose of a group is nothing less than "partnering to drive excellence in physical therapy education," you have every reason to expect that group to be doing, well…a lot of stuff. The 2018 annual report of the entities collectively known as the Education Leadership Partnership (ELP)—APTA, the American Council of Academic Physical Therapy (ACAPT), and the Academy of Physical Therapy Education (APTE)—shows how the group has been living up to that expectation while maintaining focus on important core values.

    The annual report recaps an important year for the collaborative group, documenting a year in which the partners took action on key initiatives around education research, including the approval of an educational research agenda, cosponsorship (with the Association of American Medical Colleges) of 2 medical education research certificate workshops (aka "MERCs"), the creation of an education research network, and the first-ever Grantsmanship and Mentorship in Education Research (aka "GAMER") workshop to help education researchers refine their abilities to secure grant funding.

    Education research wasn't the partnership's only area of focus, however. In 2018, the partners also held stakeholder meetings to develop action plans on clinical education, developed a framework to capture data related to physical therapist education, and provided a webinar and article, published in PTJ (Physical Therapy) on entrustable professional activities. Partnership members also formed a task force to address physical therapy program student debt.

    "It's been a busy year for the ELP," said Steven Chesbro, PT, DPT, EdD, APTA vice president of education, who helps to provide staff support to the partnership. "Progress in multiple areas is happening at a quick pace. The annual report provides a good snapshot of 2018, but we intend to keep stakeholders informed on an ongoing basis through the various partners' newsletters and other means—not only to maintain transparency, but to encourage as much participation as possible when ELP partners reach out for feedback."

    ELP comprises representatives from the 3 founding member organizations as well as ex-officio nonvoting members representing the American Board of Physical Therapy Residency and Fellowship Education, the American Board of Physical Therapy Specialties, the Commission on Accreditation in Physical Therapy Education, and the Federation of State Boards of Physical Therapy. Representatives from various areas of the clinical community—private practice, veterans, acute care, and health systems—also participate in the partnership.

    Want more information on the ELP, its history, and resources as they develop? Check out APTA's ELP webpage .

    CMS Promotes More Access to Nondrug Pain Management in Medicaid

    Could states be doing more to increase access to nonopioid and nonpharmacological approaches to management of chronic pain under Medicaid? The US Centers for Medicare and Medicaid Services (CMS) thinks so, and has issued guidance that outlines options and shares examples of some states' promising initiatives. The approaches are largely consistent with APTA's #ChoosePT opioid awareness campaign, which emphasizes the importance of patient access and choice in the treatment of pain.

    The CMS information bulletin released in late February is anchored in the US Centers for Disease Control and Prevention's (CDC) guidelines for prescribing opioids for chronic pain, published in 2016. Those guidelines, which recommend nonopioid approaches including physical therapy as the preferred first-line treatment for noncancer chronic pain, have been increasingly acknowledged and adopted by state health care entities, and early reports are positive, according to CMS. The new CMS document is designed to help states understand possible avenues for incorporating programs that help support the CDC guidelines.

    In outlining possibilities that could allow for the use of nonpharmacological approaches to chronic pain, CMS offers states a wide palette of mandatory and optional benefits, from more effective use of inpatient, outpatient, and health center services to expanded coverage for rehabilitative, physical therapy, and preventive services. The bulletin also offers home health benefits, special "demonstration" projects, and potential waivers as ways states could take creative steps to strengthen their nondrug offerings.

    CMS also offers examples of states that have changed or extended their Medicaid coverage options, including Oregon, which expanded its list of Medicaid-covered services for uncomplicated back and neck pain to include physical therapy, cognitive behavioral therapy, and other services; and California, where a 14-county Medicaid program implemented an intensive prescriber education program on nonopioid options for pain management.

    APTA has been engaged in the fight against opioid misuse in multiple ways. In addition to its flagship #ChoosePT opioid awareness campaign, the association has produced a white paper on reducing opioid use and contributed to the National Quality Partners Playbook on Opioid Stewardship. On the advocacy front, APTA continues to meet with legislators and agency representatives to address the opioid crisis, and comments on a range of topics, including a federal Pain Management Best Practices Inter-Agency Task Force draft report. Additionally, a recent formal partnership between APTA and the Department of Veterans Affairs includes collaboration to promote veterans' access to nopharmacologic approaches to pain management.

    "Providers and beneficiaries need access to effective therapy for chronic pain," CMS writes. "A multidisciplinary approach…that incorporates nonopioid pharmacologic and nonpharmacologic therapies, well-communicated treatment goals and expectations, and a careful consideration of the benefits and risks of available treatment options is the most appropriate approach for most patients and has the potential to lead to more appropriate prescribing of opioids."

    Proposed Rules on Electronic Health Information Seek Better Patient Access, More Interoperability

    With the release of proposed rules aimed at increasing the interoperability of electronic health information (EHI) among insurers and eliminating EHI "information blocking" practices, the US Department of Health and Human Services (HHS) is sending a clear signal: it intends to move ahead with a push toward making it as easy as possible for patients to access their health care records from just about any device, for free. And it won't hesitate to name the names of facilities and insurers that aren't cooperating.

    In 2 separate but related proposed rules, the US Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC)—both agencies under HHS—laid out new requirements that, if adopted unchanged, would force improvements to patient EHI access by as early as 2020.

    The proposed rules, released February 11, are complex, and APTA regulatory affairs staff are reviewing the contents to prepare comments by the anticipated early-April deadlines. At the big-picture level, a few basic ideas are emerging.

    The CMS-generated rule would require Medicare Advantage, Medicaid, Children's Health Insurance Program, and Affordable Care Act plans to provide enrollees with immediate access to their medical claims and other information by 2020, and would allow CMS to publicize the names of facilities that make it difficult or impossible for patients to access these data, according to a CMS fact sheet. The proposed rule would also require health care providers and plans to use open data-sharing technologies to make it easier for people to move between different payers.

    The proposed rule from the ONC (fact sheet) would require that health care payers and providers move to standardized application programming interfaces—techspeak for systems that make it easier for individuals to access a variety of EHI on phones and other mobile devices. Additionally, the rule would target information-blocking practices that prevent patients from accessing their own records or apply a charge for providing them. The ONC proposal would ensure that access is unrestricted and free to patients.

    The proposed ONC rule also asks for comments on pricing information that could accompany EHI to help the public get a better idea of the cost of care. The CMS proposed rule includes a request for comments on how the agency can "leverage its authority to improve patient identification and safety to encourage better coordination of care across different healthcare settings while advancing interoperability." Those settings include long-term and postacute care.

    "In a general sense, the move toward greater EHI interoperability is a concept strongly supported by APTA, but with the proposed rules coming in at more than 1,000 pages combined, it will require some time to fully understand the impact these proposals may have on physical therapists," said APTA Director of Regulatory Affairs Kara Gainer. "Once we better understand the details of the CMS and ONC proposals, we will be able to provide a more complete perspective through APTA comments and other resources and updates."

    [Editor's note: Want to add your voice to the profession's take on interoperability? During the coming weeks, be sure to check APTA's "Regulatory Issues: Take Action" webpage for template letters that make it easy to share your perspective.]

    Draft HHS Report Backs Nonpharmacological Pain Management, Calls for Better Payer Coverage of Physical Therapy

    Much like an APTA white paper on opioids and pain management published in the summer of 2018, a draft report from the US Department of Health and Human Services (HHS) says that it's time to address the gaps in the health care system that make it difficult to follow best practices in addressing pain—including improved access to and payment for physical therapy. APTA provided comments to the HHS task force that created the report.

    The draft "Report on Pain Management Best Practices" now available for public comment aims to identify "gaps, inconsistencies, updates, and recommendations for acute and chronic pain management best practices" across 5 major interdisciplinary treatment modalities: medication, restorative therapies including physical therapy, interventional procedures, behavioral health approaches, and complementary and integrative health. The entire report is predicated on a set of "key concepts" that emphasize an individualized biopsychosocial model of care that employs a multidisciplinary approach and stresses the need for innovation and research.

    The report devotes an entire section to what it calls "restorative therapies"—physical therapy, occupational therapy, therapeutic exercise, "and other movement modalities."

    "Restorative therapies play a significant role in acute and chronic pain management, and positive clinical outcomes are more likely if restorative therapy is part of a multidisciplinary treatment plan following a comprehensive assessment," the report states.

    Authors of the report point out that restorative therapies not only improve outcomes, but can "maintain functionality." The problem, they write, is that "use of restorative therapies is often challenged by incomplete or inconsistent reimbursement policies."

    The reimbursement issue is underscored later in the report, in an analysis of insurance coverage for complex pain management.

    "Although the HHS National Pain Strategy calls for greater access and coverage for pain management services, there is a lack of uniformity in insurance coverage and lack of coverage alignment with current practice guidelines for pain management," the report states. "This is particularly true for the coverage of nonpharmacologic and behavioral health interventions."

    And the problem isn't just about coverage, according to the report—there's also a disconnect when it comes to the hoops patients and providers have to go through to access the most effective pain-management approaches. "Consistently forcing providers to try a series of non-first-line treatments prior to authorizing treatment plans can be problematic, hindering appropriate patient care, creating tremendous inefficiency, and resulting in a loss of time and resources," authors write.

    The HHS report is consistent with a 2018 APTA white paper, "Beyond Opioids: How Physical Therapy Can Transform Pain Management to Improve Health." In that resource, APTA recommends the adoption of public and public health plan benefit models that support early access to physical therapy and other nonpharmacological interventions for pain, and a reduction or elimination of out-of-pocket costs for those approaches.

    Recommendations in the HHS report include stepped-up research on which restorative therapies are the best fit for specific pain syndromes, and minimizing barriers to patient access to them. On the insurance front, the report recommends that the US Centers for Medicare and Medicaid Services and other payers reimburse pain treatment using a chronic disease management model "in the manner they currently reimburse cardiac rehabilitation and diabetes chronic care management programs." The task force also recommends "innovative payment models that recognize and reimburse holistic, integrated, multimodal pain management, including complementary and integrative health approaches."

    APTA will be submitting comments on the draft report, and encourages members and other stakeholders to do the same by the April 1 deadline. The association has even developed a template comment letter that makes it easy to provide your insights—for more information and to download the template letter, visit APTA's regulatory "Take Action" webpage.

    APTA continues to build on its successful #ChoosePT campaign to educate the public on safe, effective alternatives to opioids for pain management. The most recent addition: a downloadable pain profile chart that makes it easy for patients to assess the severity and impact of the pain they're experiencing.

    New CPT Codes Allow PTs to Conduct, Bill for Remote Monitoring

    Sure, the biggest news from the 2019 Medicare physician fee schedule is the new reporting and payment system for many physical therapists (PTs), but that's not the whole story: the 2019 rule also includes new current procedural terminology (CPT) codes that allow PTs to conduct and bill Medicare for remote monitoring of patient factors such as weight, blood pressure, and pulse oximetry.

    Many questions remain as to how the US Centers for Medicare and Medicaid (CMS) will implement the new codes, and APTA is developing online resources that will supply further details as they become available.

    Here's what APTA knows so far: the new CPT codes apply to chronic care, and they allow physicians, clinical staff, or "other qualified healthcare professionals" to conduct remote monitoring in certain circumstances. Because PTs are included in the American Medical Association’s definition of  "qualified healthcare professionals" they are able to participate in the remote monitoring to the extent allowed by state and scope-of-practice laws.

    And while it's true that these services are provided remotely, because they are inherently non face-to-face CMS doesn't consider the activities to fall under "telehealth." That's an important distinction, because under current CMS rules, PTs aren't among the providers permitted to furnish telehealth services.

    The new codes are:

    • Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month (99457)
    • Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment (99453)
    • Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days (99454)

    CMS intends to issue guidance on how exactly the codes can be used, but the agency did supply an important detail when the new rule was released: namely, that CPT code 99457 cannot be furnished "incident to" another provider’s professional services.

    APTA Partners With VA to Raise Vets' Awareness of Physical Therapy, Create Practice Opportunities for PTs and PTAs

    The link between the physical therapy profession and services to military veterans has always been strong, but recently the relationship received a boost in the form of an official partnership between APTA and US Department of Veterans Affairs (VA) to promote and enhance the health of the nation's veterans.

    On December 28, VA and APTA announced a memorandum of agreement (MOA) that "coordinates the strengths of both organizations to benefit all Veterans and their families, physical therapists, and physical therapist assistants by helping to raise awareness of physical therapy and create new employment and practice opportunities," according to a VA news release.

    APTA and VA will combine efforts in multiple areas including suicide prevention, promotion of nonpharmacological approaches to pain treatment, and greater physical therapist (PT) and physical therapist assistant (PTA) participation in VA sports programs and special events.

    "APTA finds its roots in the military, and we are thrilled to be partnering with VA to give back to America's veterans and ensure that they are receiving the physical therapy care they need," APTA CEO Justin Moore, PT, DPT stated in an APTA news release. "I am confident this agreement will lead to even better health care, results, and, ultimately, improved quality of life for them."

    APTA predicts the collaboration will have "local and national impact" and describes the partnership as a good fit with the association’s mission to build a community that advances the physical therapy profession to improve the health of society.

    “Physical therapy is an important resource for improving Veterans’ health and well-being,” said VA Secretary Robert Wilkie in the VA news release. “This new agreement allows both organizations to develop additional best practices in treatment of Veterans in both the federal and private sector. We look forward to the positive outcomes of this partnership.”