Scroll down the page to see what 2018 will bring related to the Medicare fee schedule and therapy cap, postacute care reform, the Comprehensive Care for Joint Replacement program, evaluation codes, and functional limitations reporting, among other things.
Focus on Value
Medicare is shifting away from the fee-for-service payment structure, in which providers are rewarded solely by the volume of services provided, and toward a structure that holds providers accountable for patient outcomes and costs. This move to value-based care is intended to advance the goals of health care's "triple aim"—improving the patient experience of care (including quality and satisfaction), bettering the health of populations, and reducing the per-capita cost of health care. Physical therapists (PTs) must quickly identify opportunities to become engaged in value-based payment models.
Value-based payment models often are referred to as alternative payment models (APMs). An APM is a payment approach that incentivizes providers to collaborate to provide high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population.
To navigate value-based payment, providers will need data. PTs will need to understand and promote the value they bring to the health care system and to the models in which they participate. Value in health care typically is expressed as quality (outcomes of care and patient experiences) divided by cost (direct and indirect). PTs need to know their outcome and cost data at the individual and practice level, as well as for the APM in which they participate, in order to determine how their performance and that of the group as a whole may affect payment.
To help PTs transition to value-based payment, APTA launched the Physical Therapy Outcomes Registry (Registry) in early 2017. The Registry enables PTs to make improved data-informed clinical decisions, track and benchmark outcomes against industry data, and demonstrate the value of physical therapist services. It directly integrates with EHR systems to seamlessly and securely transfer data to a database of patient episodes. The database provides immediate profession-wide benchmarking and informs future research. The Registry is now accepting facility enrollments, ranging from small private practices to large, multisite organizations.
To learn more about how to move into value-based payment models, see APTA's Value-Based Payment webpage. To learn more about contracting with APMs, please see the Alternative Models Under Medicare webpage.
Permanent Fix to the Therapy Cap in 2018
- As part of the Bipartisan Budget Act of 2018, legislation, Congress finally enacted a permanent solution to the problematic hard cap on outpatient physical therapy services under Medicare Part B, ending a 20-year cycle of patient uncertainty and wasteful short-term fixes. Visit APTA's Medicare Therapy Cap webpage for details.
- Therapists should review APTA guidance on targeted manual medical review if they are notified by the Supplemental Medical Review Contractor.
The Centers for Medicare and Medicaid Services (CMS) issued several payment updates and policy changes that will affect the physical therapy profession in 2018 and beyond.
What to Know about 2018 Changes to Fee Schedule Payments
Effective for services provided on or after January 1, 2018, the 2018 fee schedule conversion factor is 35.99, which reflects the +0.5% update factor specified under MACRA, reduced by 0.9%, due to the misvalued code target recapture amount and a budget neutrality adjustment. CMS made both positive and negative adjustments to the values of several highly utilized CPT codes in the physical medicine and rehabilitation family, including manual therapy, therapeutic exercise, therapeutic activities, and neuromuscular re-education. Because of the wide variation in upward and downward adjustments, the impact on an individual physical therapist will depend on the types of patients the PT or clinic typically sees and what interventions are commonly used. To learn more about these changes, please see APTA's Medicare Physical Fee Schedule webpage.
To help PTs clear up some of the uncertainty, APTA has updated the 2018 Medicare Physician Fee Schedule calculator to reflect the most up-to-date values issued by CMS and to help you better determine how your typical case-mix will fare in 2018.
Quality Payment Program
The Medicare Access and CHIP Reauthorization act of 2015 (MACRA) established the Quality Payment Program (QPP), a quality incentive program for eligible clinicians that rewards value and outcomes via 1 of 2 tracks: the Merit-based Incentive Payment System (MIPS) and Advanced APMs.
MIPS: Clinicians participating in MIPS earn a performance-based payment adjustment to their Medicare payment, based on a score derived from evidence-based and practice-specific quality data in the following 4 categories: Quality (from the former PQRS); Improvement Activities; Advancing Care Information (from the former Meaningful Use initiative); and Cost. Although PTs are not eligible for mandatory participation under MIPS in 2018, many of them can voluntarily report their quality data. APTA strongly encourages members to voluntarily report, as it will help prepare the profession for potential mandatory participation and to advocate for policy changes necessary to ensure that PTs can be successful in MIPS.
To learn more, please visit APTA's webpage on MIPS.
Advanced APMs: Advanced APMs are a subset of APMs that let clinicians and practices earn more for taking on risk related to their patient's outcomes. Clinicians may earn a 5% incentive payment by participating in an Advanced APM if they meet set minimums for the amount of Medicare Part B payments received or number of Medicare Part B patients treated through the Advanced APM. Most clinicians in Advanced APMs will be Qualifying APM Participants (QP) and eligible to receive the incentive payment. A QP determination status lookup tool is available for eligible clinicians to review. To learn more about specific Advanced APMs, visit the CMS Innovation Center website.
Coming soon: APTA has developed a comprehensive podcast series on value-based care and payment. Look for a link here in January 2018.
Postacute Care Reform
Although proposed payment policy changes for home health agencies (HHA) and skilled nursing facilities (SNF) were not finalized for implementation in 2018, Medicare is determined to improve payment accuracy for HHA and SNF patients. In future years, it is likely we will see the connection between therapy utilization and payment eliminated. It is important for the physical therapy profession to be aware of the ever-evolving changes. To stay up-to-date on postacute care reforms, visit our Medicare Postacute Care Reform webpage.
Functional Limitation Reporting
Despite changes elsewhere in payment and quality reporting, functional limitation reporting (FLR) continues in 2018 as before. APTA has numerous resources to help you navigate functional limitation reporting, including an online complaint form (APTA member login required) who need staff assistance.
Comprehensive Care for Joint Replacement Model
In December 2017, CMS made several policy changes to the Comprehensive Care for Joint Replacement Model (CJR) Model, including broadening the scope of clinicians eligible for the Advanced APM bonus payment if they contract with a hospital participating in the Advanced APM track of the CJR model.
The new policies are as follows:
- Fewer CJR mandatory participation areas. CMS reduced mandatory CJR participation from 67 metropolitan areas to 34; eligible hospitals in the other 33 areas may participate voluntarily. Low-volume and rural hospitals are exempt from mandatory participation in all 67 areas, but they also may participate voluntarily.
- Canceled episode payment models for acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture, and for the cardiac rehab incentive payment model. These were set to begin on January 1, 2018.
- More clinicians eligible to receive Advanced APM bonus. PTs who contract with Advanced APM CJR Model participant hospitals, and PTs who are CJR collaborators, may be determined by CMS as Qualifying APM Participants. APTA has resources to help you better understand your options for participation in the CJR Model. Check out these resources.
Evaluation and Reevaluation Codes
In 2018, Medicare is maintaining a single payment rate for all of the 3 tiered evaluation codes that were implemented in 2017, saying it will continue to collect utilization data before considering any changes. This means it's imperative that PTs continue to document the medical necessity of their evaluations and accurately choose the appropriate codes, to ensure that Medicare has complete data for potentially striating payment rates in the future. You can find APTA resources to help you make the appropriate determinations on our webpage dedicated to the tiered evaluation and reevaluation codes. Review these resources.