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  • 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.”

    The More Things Change, the More They…Change: CMS Announcements Dominate Top PT in Motion News Stories for 2018

    Looking back over 2018, it's hard to overstate the magnitude of Medicare-related changes experienced by physical therapists (PTs), physical therapist assistants (PTAs), and their patients. It was a year that included the end of the hard cap on therapy services under Medicare and the announcement of the inclusion of qualifying PTs in its Quality Payment Program starting in 2019—a dramatic shift toward value-based payment. And did we mention the launch of new requirements for skilled nursing facilities (SNFs) beginning later in 2019?

    While payment news is almost always of interest to PT in Motion News readers, keeping up with the US Centers for Medicare and Medicaid Services (CMS) was apparently top-of-mind in 2018, as Medicare-related stories dominated this year's list of most-read News items.

    Here's what grabbed the attention of readers in 2018:

    A permanent fix to the Medicare therapy cap was finally approved...
    In early February, Congress enacted change that ended the hard cap on therapy services under Medicare part B, putting to rest "a 20-year cycle of patient uncertainty and short-term fixes."

    …but not before the cap was applied for a few weeks.
    When 2017 ended without the usual 11th hour temporary fix in place, the therapy cap was triggered for the first weeks of 2019, throwing PTs and patients into (fortunately, short-lived) uncertainty.

    The post-therapy cap world has its own requirements.
    Instead of a hard cap, CMS began relying on the KX modifier threshold for physical therapy and speech-language pathology—and yes, the monetary limits were still combined. PT in Motion News published a list of "5 basics you need to know" about the new approach.

    SNFs need to prepare for a new payment landscape in 2019.
    CMS unveiled a proposed rule for SNFs in 2019 that replaces the Resource Utilization Groups Version IV (RUG-IV) with something new—the Patient-Driven Payment Model. This story from April breaks down the basics of the proposal.

    Even more dramatic changes to come: QPP and MIPS are on the way.
    When the proposed 2019 physician fee schedule from CMS contained what many expected was coming: the inclusion of qualifying PTs in the agency's Quality Payment Program (QPP) and its Merit-based Incentive Payment System (MIPS). This PT in Motion News story presented the basics of a major shift in payment and reporting for PTs.

    DoD Moves to Include PTAs in TRICARE

    Nearly a year after being signed into law, the wheels are finally turning: a proposed rule to include physical therapist assistants (PTAs) as authorized providers under TRICARE, the health care system used throughout the military, has been issued by the US Department of Defense (DoD). APTA strenuously advocated for the change and says it's time for supporters to help push the rule over the finish line.

    The proposed rule is a fairly straightforward plan that seeks to have the TRICARE system adopt Medicare's requirements for PTAs and occupational therapy assistants (OTAs). "This rule will align TRICARE with Medicare's policy, which permits PTAs and OTAs to provide physical or occupational therapy when supervised by and billed under a licensed physical therapist or occupational therapist," DoD writes in its summary of the proposal.

    According to Kara Gainer, APTA's director of regulatory affairs, the proposal, while strongly supported by APTA, has a few issues that need to be addressed.

    "The rule references 'physical therapy assistants' when it should be 'physical therapist assistant'—that area, and a few other places in which DoD uses inconsistent language around physical therapist qualifications, are easy fixes and something that we'll be recommending," Gainer said. "Overall, however, the release of this proposed rule is a very positive step because it starts the clock ticking toward final implementation."

    The timeline for when PTAs could actually begin participating in TRICARE was an uncertainty that lingered throughout 2018—although DoD intended to have the change in place no later than 2021, nobody seemed to know just when the rulemaking process would begin. The publication of the proposed rule kicks off a series of timelines that put progress on a more trackable schedule, beginning with a 60-day deadline for public comment. According to an APTA chart on possible implementation of the rule (scroll down to view), PTAs could be participating in TRICARE as early as fall of 2019, or as late as early 2020 if all goes according to plan.

    What's next? APTA urges supporters of the change to make that support known to DoD by providing comments on the proposed rule by the February 19, 2019, deadline. In early January, APTA will offer a template letter that will make the comment process easy—be on the lookout for an announcement when that becomes available, or look for the letter on APTA's "Take Action" webpage sometime after January 1, 2019.

    New Physical Activity Guidelines Stress the Importance of Movement of any Duration

    You want blunt? The US Department of Health and Human Services can do blunt—at least when it comes to physical activity (PA) recommendations for Americans.

    "Adults should move more and sit less throughout the day," HHS says in its latest edition of nationwide guidelines for PA. "Some physical activity is better than none."

    That's the bottom-line recommendation that HHS rolled out this week in its revised Physical Activity Guidelines for Americans. And there's arguably little room for nuance: according to HHS, 80% of all Americans are not meeting current PA recommendations, a failure that is contributing the prevalence of a host of chronic health conditions.

    The new guidelines, with their emphasis on the importance of movement to prevent disease and extend life no matter an individual's age, echo many perspectives long-championed by APTA and its members.

    "These revised guidelines create a clear roadmap for where we need to be as a nation, and the physical therapy profession is here to help people get the movement they need to optimize their health," said APTA President Sharon L. Dunn, PT, PhD. "APTA will continue to advocate on behalf of our patients to ensure that our nation’s public policies align with these recommendations."

    The revision, the first in 10 years, doesn't alter many of the now-familiar PA goals for adults: at least 150 minutes of moderate-intensity PA per week, or 75 or more minutes of vigorous-intensity PA per week. But the new guidelines further reinforce the benefit of PA at any level by removing statements saying that PA must occur for at least 10 minutes to be effective, and by clarifying that virtually any kind of movement is better than nothing. "Adults who sit less and do any amount of moderate-to-vigorous [PA] gain some health benefits," according to the guidelines.

    The guidelines themselves vary by age and other factors. Here are the basics for each group identified by HHS.

    Preschool-aged children (3 to 5 years): HHS recommends that this age group "should be physically active throughout the day" and that caregivers "should encourage active play that includes a variety of activity types."

    Children and adolescents (6 to 17 years): The guidelines recommend 60 minutes or more per day of moderate-to-vigorous PA; with at least 3 days of vigorous-intensity PA per week, at least 3 days of muscle-strengthening PA per week, and at least 3 days of bone-strengthening PA per week.

    Adults: 150 minutes per week of moderate-intensity PA, or 75 or more minutes per week of high-intensity PA is recommended for adults; at least 2 or more days per week should include muscle-strengthening activities.

    Older adults: If possible, 150 minutes per week of moderate-intensity PA, tempered by an individual's "level of [PA] relative to their fitness," and a clear understanding of how various chronic conditions can affect the ability to reach PA goals. No matter what PA level is achieved, activities should include balance training, aerobic, and muscle-strengthening activities.

    Women who are pregnant and postpartum: The guidelines recommend at least 150 minutes of moderate-intensity PA per week, spread throughout the week, during both pregnancy and postpartum. The guidelines also advise that women "who are habitually engaged in vigorous-intensity aerobic activity or who were physically active before pregnancy can continue these activities during pregnancy and the postpartum period."

    Adults with chronic health conditions and/or disabilities: These adults should follow the same targets as nonsymptomatic adults, but with a recommendation that should a chronic condition or disability interfere with their ability to meet these guidelines, PA should occur to whatever extent possible; individuals should avoid inactivity. The guidelines also recommend that people with chronic conditions "consult with a health care professional or [PA] specialist about the types and amounts of activity appropriate for their abilities and chronic conditions."

    A summary of the guidelines was featured in JAMA, accompanied by an editorial that emphasizes the importance of educating the public on the idea that PA has health benefits no matter the scale of the effort.

    "Probably the most important message…is that the greatest health benefits accrue by moving from none to even small amounts of [PA], especially if that activity is moderate…to vigorous..." editorial authors write. "The key point for patients is that large health benefits accrue from even small amounts of [PA] and that even short-duration activity lasting less than 10 minutes is beneficial."

    The JAMA editors also think that clinicians need to take care to avoid an overly cautious approach to PA recommendations for patients, writing that they "must avoid being a barrier to [PA] because of concerns about the cardiovascular and orthopedic risks…." They describe those risks as "extremely small with gradually progressive [PA]."

    Given PA's demonstrated effects on both physical and emotional well-being, and the relatively low costs involved in incorporating PA into patient lifestyles, "clinicians cannot afford to allow patients to miss out on this inexpensive path to healthier lives," the editorial authors write.

    Visit APTA's prevention and wellness webpage for resources on how physical therapists and physical therapist assistants can help individuals become more physically active, and share the latest PA information from APTA's consumer-focused MoveForwardPT.com with your patients, clients, and others interested in the benefits of exercise and movement. Want to connect with others interested in physical therapy's role in improving health? Join APTA's Council on Prevention, Health Promotion, and Wellness.

    Proposed Medicaid, CHIP Rule Reflects State Movement Toward Managed Care Systems

    As states continue to move toward wider use of managed care organizations (MCOs) in their Medicaid systems, the US Centers for Medicare and Medicaid Services (CMS) is looking at ways to guide the evolution while maintaining state flexibility. A few of those ideas have been fleshed out in a recently released proposed rule from CMS on both Medicaid and the Children's Health Insurance Program (CHIP).

    APTA regulatory affairs staff members are analyzing the proposed rule, and the association will provide comments to CMS by the January 19, 2019, deadline. In the meantime, here are a few basics:

    Allowing temporary pass-through payments for states transitioning to MCOs. Currently, providers in fee-for-services Medicaid arrangements are eligible for additional payments, known as "pass-through" payments, but these payments are being phased out for MCO Medicaid arrangements, and new payments are prohibited. But what about states that are transitioning to managed care? In response to some states' requests that pass-throughs continue to be allowed as a part of the transition process, CMS is proposing that new payments be allowed during a limited time period.

    Easing network adequacy standards and providing flexibility in the definition of "specialist." CMS proposes moving away from network adequacy standards based on travel time and geographic location, and toward a system that allows states to factor in other issues, including the availability of contracted providers who are accepting new patients, maximum wait times for appointments, and a facility's hours of operation. Additionally, the agency would like to give states more flexibility in defining which providers are considered "specialists."

    Loosening requirements for state quality-rating systems (QRS). CMS would like to allow states more leeway in their QRS systems: rather than requiring that the approaches provide data substantially similar to data provided by the CMS-developed QRS, the agency is proposing that state QRS systems need only be "comparable to the extent feasible to enable meaningful comparison across states." The proposed rule also would eliminate a requirement that states get CMS approval before starting up an alternative QRS.

    Making it easier for enrollees to navigate the appeals system. Under the proposed rule, Medicaid enrollees would no longer be notified of claims denials based on administrative errors; they would only receive notification of "substantive" denials. Additionally, enrollees who submit an oral appeal to a denial would no longer be required to submit an additional written and signed appeal.

    CMS Finalizes 'Site Neutral' Outpatient Plan; New Approach to DMEPOS Bidding

    As it continues to roll out final payment rules for 2019, the US Centers for Medicare and Medicaid Services (CMS) is sticking to its pattern of mostly following through on its original proposals—this time by ending payment rates that favor hospital-owned outpatient facilities over independent physicians' offices, and adopting a new supplier bidding system for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).

    Outpatient Prospective Payment System (OPPS)
    As it proposed, CMS will expand the use of a "site-neutral" payment model in its reimbursement for the clinic visit service (HCPCS G0463), the most common service billed under the OPPS. Currently, Medicare and beneficiaries often pay more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting. CMS is doing away with the current system that pays so-called "off-campus" hospital-owned facilities an estimated $75 to $85 more than it does independent counterparts for this service. According to a CMS fact sheet, the agency estimates that the change, implemented over a 2-year period, will save an estimated $380 million in 2019 alone. The change does not directly affect physical therapists (PTs) working in outpatient hospital settings, given that outpatient therapy services delivered by PTs are paid under the physician fee schedule, not OPPS.

    Also final-as-proposed: a CMS decision to make separate payments for nonopioid pain-management drugs that function as a supply when used in an ambulatory surgical center (ASC) procedure.

    Overall, OPPS rates will increase by 1.35% in 2019, with a 2.9% market basket update offset by a 0.8% productivity adjustment and a 0.75% adjustment related to the Affordable Care Act (ACA). ASC payment will increase by 2% and in the future will be updated based on the hospital market basket update instead of the "consumer price index-urban all item" system, a change that will remain until 2023 at the earliest.

    Although not reflected in the final rule, during the public comment period on the OPPS proposed rule, CMS asked for input on issues including wound care, price transparency, and the opioid crisis as it relates to outpatient services. APTA provided comments in all 3 areas, advocating for better promotion of and payment for nonopioid approaches to pain management, a collaborative approach to price transparency that emphasizes consumer education, and careful attention to wound care reimbursement recommendations provided by the Alliance of Wound Care Stakeholders, of which APTA is a member.

    Resources:
    CMS fact sheet on OPPS final rule
    Complete OPPS final rule

    DMEPOS
    The biggest news in the DMEPOS arena is the CMS decision to move ahead with its proposal to use "lead item pricing" as a way to improve competitive bidding for DMEPOS. The system eliminates the need for suppliers to submit multiple different bids on items in a product category—instead, they can anchor bids to an item with the highest Medicare-allowed charges in a product category, folding in services and equipment directly related to providing the item (as appropriate). CMS hopes this "composite bid" approach will simplify the bidding process and ease burdens on suppliers.

    APTA generally supported the proposal but shared concerns with CMS over creating lead pricing categories that are overly large, including an unwieldy range of DMEPOS. In response, CMS assured commenters that the system would be built around "discrete categories of like items that are generally provided together to address a beneficiary’s medical needs." CMS also assured APTA and other commenters that the lead pricing system would not allow suppliers to win bids on categories that they do not cover in full.

    In a second move supported by APTA, CMS followed through on a proposal to continue to apply a 50/50 blend of adjusted and nonadjusted reimbursement rates to "noncontiguous areas"—primarily Alaska and Hawaii. In its comments to CMS, the association urged the agency to consider the challenges faced by rural and noncontiguous areas when it comes to distances that must be covered to receive or provide care. CMS said that those challenges had been factored into its final rule.

    Resources:
    CMS fact sheet on DMEPOS final rule
    Complete DMEPOS final rule

    Physician Fee Schedule and QPP: A New Payment World Awaits PTs in 2019

    Many physical therapists (PTs) will face a new payment landscape beginning in January, now that the US Centers for Medicare and Medicaid Services (CMS) has finalized a rule that ends functional limitation reporting (FLR) and moves certain PTs into the Quality Payment Program (QPP). That program, which includes the Merit-based Incentive Payment System (MIPS), is at the center of a sweeping shift toward value-based payment in Medicare.

    The confirmation of PTs' inclusion in QPP came in conjunction with the release of the final 2019 physician fee schedule. For PTs and physical therapist assistants (PTAs), the final versions by-and-large mirror the rule proposed by CMS earlier this year. But a few important changes and clarifications, some in response to comments from APTA and other stakeholders, are worth noting—particularly in regard to the way CMS wants to approach coding and paying for services delivered totally or "in part" by a PTA or occupational therapy assistant (OTA).

    APTA regulatory affairs staff are reviewing the final rule and will publish a detailed summary in the coming weeks. In the meantime, here are some highlights.

    Bottom line: get ready for MIPS and other components of the QPP.
    It's official: beginning in 2019, PTs in private practice who furnish services under Medicare are included in QPP, an entirely new payment system for the profession. Under QPP, qualifying PTs have a choice of participating in the Merit-based Incentive Payment System (MIPS) or—if available to them—an advanced alternative payment model (Advanced APM). A subset of these PTs who meet volume thresholds will be required to participate in one or the other. PTs in private practice who don't qualify for participation in MIPS can do so voluntarily, something APTA encourages given that all signs point to further expansion of the QPP in the future.

    The program—particularly MIPS—is largely centered on reporting requirements. MIPS requires reporting in 4 performance categories (PTs in 2019 will be required to report under only 2 categories: quality and improvement activities), with providers earning points in each category. An annual MIPS score will determine whether the providers earn a payment incentive, remain neutral in payment, or are subject to a penalty. Several of the data points must be reported electronically through certified electronic health record (EHR) vendors or registries such as APTA’s Physical Therapy Outcomes Registry.  

    The Advanced APM-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. The rule also includes an option for QPP participation through a Medicare Advantage demonstration.

    In addition to its acknowledgement of PTs as providers who are integral to the evolution toward value-based care, CMS also included a welcome change: the elimination of functional limitation reporting (FLR), a fraught system that met with criticism from APTA since its implementation.

    But that's just the big-picture picture. PTs and PTAs are well-advised to learn as much as possible about QPP and MIPS sooner rather than later, and to understand how this major shift may impact their practice. Scroll down to the end of this article for suggested links that help to fill in the details of how the program works.

    In terms of the fee schedule itself, the required adjustment factor for 2019 is 0.25% before applying other adjustments. But remember: this is the last year there will be an update to the physician fee schedule through 2025. Beginning in 2026, payment rates will be updated based on the eligible clinician’s participation in MIPS or Advanced APMs.

    CMS efforts to clarify PTA-related coding are a mixed bag.
    CMS was required by law to establish modifiers to indicate services provided by PTAs and OTAs. In the final rule, CMS clarifies that services furnished in whole or in part by a PTA or OTA will be identified –through payment modifiers—"CQ" for services delivered by a PTA and "CO" for services delivered by an OTA. The definitions of the therapy services codes (GP, GO, GN) remain unchanged. The new payment modifiers for services furnished by PTAs and OTAs are not required on claims until January 1, 2020.

    The PTA and OTA issue isn't just about coding, however. CMS is also attempting to specify what it means by services delivered "in part" by a PTA or OTA. Despite significant advocacy efforts by APTA and other stakeholders, CMS made only a moderate change between the proposed and final definition of services furnished “in part.” In the final rule, CMS adopts a "de minimis" standard, establishing that anything over 10% of the total patient service delivered by a PTA constitutes "in part" services. Although many questions remain, CMS has stated it will further clarify the de minimis standard in 2020 rulemaking. APTA had advocated that CMS hold off on making a final decision on this issue until the agency gathered more information from stakeholders or, if it did move forward, that it adopt a higher bar for what constituted services delivered "in part" by a PTA or OTA.

    The modifiers and definition of services furnished “in part” are crucial concepts as CMS moves toward the implementation of an 85% payment differential for services delivered "in part" by PTAs beginning in 2022. There will be more opportunities for APTA to advocate on changes to the definition of “in part” in future fee schedules leading up to the 2022 final rule, and the association will continue to advocate for changes to the proposal. Among the association's concerns: the potential impact of the differential on patient access, particularly in rural and medically underserved areas.

    The KX modifier isn’t going away, and the therapy threshold amount will get a (tiny) boost.
    As CMS prepares for its second year in a post-therapy cap environment, it's holding on to the KX modifier process for claiming outpatient therapy services over a specified amount—next year, $2,040, compared with $2,010 in 2018. As is the case in 2018, that amount will be for physical therapy and speech-language pathology services combined.

    CMS will consider ways to facilitate participation in Advanced APMs by nonphysicians who may not use certified electronic health record technology (CEHRT) due to lack of certified systems for their specialties.
    APTA joined a host of other commenters in suggesting that nonphysician provider participation in Advanced APMs would be hindered by a CMS proposal to increase the CEHRT minimum use threshold—an important consideration, given that participation in an Advanced APM is one way qualified providers are supposed to be able to meet QPP requirements. The argument made by APTA and others was that CEHRT standards are built around the particulars of physician-focused electronic health records (EHRs) that aren't as applicable to nonphysician EHRs, thereby creating an artificial barrier to nonphysician participation in APMs.

    Not so, CMS responded in the final rule. "We reiterate that the Advanced APM minimum CEHRT-use threshold applies to APMs and the requirements they impose on participating APM Entities, not to the individual APM Entities participating in APMs," CSM writes. "This means there can be a percentage of eligible clinicians participating in an APM Entity who are not using CEHRT and the APM Entity will still be in compliance with the APM’s terms and conditions." However, CMS has promised to monitor the situation and consider possible solutions to facilitate participation in Advanced APMs by nonphysicians and nonprescribing eligible clinicians in the future.

    PTs are still mostly excluded from allowances for telehealth—but APTA has convinced CMS to think about making changes.
    Despite APTA's advocacy, the final rule allowing for "virtual check-ins" applies only to providers who are qualified for reimbursement for evaluation/management services—in other words, not PTs. Additionally, PTs aren't included among providers who can be reimbursed for "interprofessional internet consultations."

    This situation is fluid, however. CMS responded to APTA’s calls for more PT inclusion in telehealth by stating that it would consider exploring a demonstration or pilot through its Center for Medicare and Medicaid Innovation. And if a proposed Medicare Advantage (MA) rule is any indication, CMS may be seeing the light—that proposal allows MA plans to include telehealth services as a "basic benefit," and APTA is pressing for PTs to be included in the list of qualified providers who may furnish telehealth services to MA enrollees.

    "All in all, the final fee schedule and QPP rule is what was expected, but what was expected is a significant shift in payment methodology," said Kara Gainer, APTA's director of regulatory affairs. "It's now critically important that physical therapists learn as much as possible about QPP and how they can best navigate the new system."

    Learn more about QPP, MIPS, and APMS

    • APTA's MIPS webpage: includes articles, recorded webinars, podcasts, decision-making guidance for voluntary participation, links to a MIPS discussion board, and more.
    • APTA's QPP webpage: take a readiness quiz, watch a short video, download recorded webinars, get detailed fact sheets, connect with other websites, and more.
    • "Moving Toward Quality Payment" (November PT in Motion magazine feature)