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At more than 2,000 pages, the U.S. Centers for Medicare & Medicaid Services' proposed 2023 Medicare Physician Fee Schedule isn't going to make anyone's top-10 beach reads list. It does, however, contain some proposals that the physical therapy community needs to understand — and at least two opportunities to shine a spotlight on the profession.

APTA has published two reviews of the proposal (part 1, part 2), discussed the basics in a recent podcast and recorded webinar, and produced an issue brief explaining one of the rule's payment provisions.

Now, with the proposed fee schedule officially published, it's time to focus on targets for advocacy. Here are four important things to consider.

1. The 4.4% cut to the conversion factor would affect a wide range of providers and threatens patient access to needed services.

In an expected move, CMS proposed another decrease in the conversion factor, one of the elements used in calculating final payment amounts for various codes. This time around, the conversion factor is $33.0775, a 4.42% decrease from the $34.6062 conversion factor adopted in 2022.

It's nearly impossible to pinpoint exactly how this cut would affect PTs as a whole, because so much depends on the individual mix of codes used, geographic adjustments by CMS, and other factors. Still, there's little doubt the cuts will be felt: If finalized, the rule would result in the conversion factor dropping below early 1990s levels. The cuts would add to the pressure on PTs to do more with less and ultimately put patient access to care at risk.

The cuts are part of CMS' effort to make up for increases to payment for codes associated with office/outpatient evaluation and management codes and adopting a new add-on code (G2211) eligible to be billed by physicians. Because the agency is required by law to maintain budget neutrality, the increases need to be offset by decreases elsewhere. Targeting the conversion factor spreads the pain as widely as possible.

This isn't the first time CMS has gone after the conversion factor. In its proposed rules for both 2021 and 2022, the agency pursued the same strategy, but Congress stepped in at the 11th hour with additional appropriations that blunted some of the severity of the cuts.

At the same time, lawmakers suspended sequestration cuts mandated by the 2011 Budget Control Act, an annual 2% cut that has been a regular feature of Medicare budgets since 2013. A complete suspension was enacted in 2021; in 2022, sequestration cuts returned but were phased in, with the full 2% cut implemented in the beginning of July. At this point, it's unclear whether Congress will take similar actions to buffer the cuts to the conversion factor, and it seems unlikely that the sequestration cuts will be suspended again.

Next steps: The proposed cuts must be opposed. APTA will be providing comments to CMS by the Sept. 6 deadline that will articulate why the cuts are a bad idea, and the association is urging members and stakeholders to submit their own comment letters (more on that below). When writing individual comment letters, it's important to share how the cuts could impact your practice — especially when it comes to your ability to provide needed services to patients.

The advocacy push isn't limited to CMS. On Capitol Hill, APTA is working its advocacy channels to call lawmakers' attention to the cuts and make the case for another infusion of funding along the lines of the help that was provided over the last two years. At the same time, the association and multiple other organizations are urging Congress to rethink the entire physician fee schedule, a system that is antiquated and broken.

2. CMS wants to hear about underutilized services in Medicare. This is a significant opportunity to make the case for physical therapy.

It's not unusual for CMS to ask for input on specific areas of various rules, but lately the agency has been soliciting input on more broad issues (for instance, for the past few years it's been gathering perspectives on health care disparities and social determinants of health). Now CMS is calling for perspectives on high-value services that aren't used enough under Medicare. Did someone say physical therapy?

"In light of the concerns regarding the potential underutilization of high-value health services, particularly among potentially underserved communities, we are committed to promoting these high-value services within the Medicare program," CMS states in the proposed rule. "In concert with the CMS strategy to advance health equity in addressing health disparities that underlie our health system, we seek to engage with interested parties and solicit comment regarding ways to identify and improve access to high-value, potentially underutilized services by Medicare beneficiaries."

Next steps: The CMS call for comment is an opportunity that cannot be missed. Through collective APTA comments and the perspectives of individual PTs, PTAs, and supporters, we can make a compelling case for physical therapy as a cost-effective pathway toward patient-centered care that achieves better outcomes. The evidence base for that argument is overwhelming, and stories of individual practitioners will bring exactly the kind of on-the-ground perspectives that CMS is seeking in comments.

[Tip: Be sure to share your story with CMS, including what services you offer, what populations you serve, and what the cost savings are to Medicare when you do. Don’t forget to include barriers to care – such as plan-of-care signatures, poor reimbursement rates, and physician and patient awareness of physical therapy as preventive care. This is an excellent time to highlight all that PTs and PTAs do to reduce falls, avoidable injuries, opioid dependence, unnecessary surgeries, and much more.]

3. CMS is considering making virtual direct supervision of PTAs permanent and wants input on the idea — another great opportunity that we need to seize.

During the public health emergency, CMS relaxed its supervision requirements for PTAs (and multiple other provider groups) to allow for direct supervision to be conducted virtually under Medicare. Now the agency is asking if the waiver should be made permanent, at least for some.

"While we are not proposing to make the temporary exception to allow immediate availability for direct supervision through virtual presence permanent, as with last year's rulemaking (86 FR 39149-50), we continue to seek information on whether the flexibility … should potentially be made permanent," CMS writes in the proposed rule. "We also seek comment regarding the possibility of permanently allowing immediate availability for direct supervision through virtual presence …  for only a subset of services, as we recognize that it may be inappropriate to allow direct supervision without physical presence for some services due to potential concerns over patient safety."

APTA has long argued that while necessary, supervision requirements are often needlessly burdensome — that's certainly the case in the outpatient setting, where direct face-to-face supervision of PTAs is mandated outside of the public health emergency.

Next steps: As with the call for input on underutilized services, this request from CMS presents one of the profession's best opportunities in years to fix supervision requirements. APTA will submit its broadly voiced argument for the change, and will urge individual members and supporters to provide CMS with their personal perspectives on how relieving the face-to-face requirement could lead to improved patient care.

4. CMS wants to hear from individual providers, and new APTA resources make it easy to craft individualized comment letters.

This isn't specifically laid out in the proposed fee schedule, but CMS is increasingly taking a different approach to how it considers comment letters. While the comments from APTA and other stakeholder organizations will still be crucial, the agency says it will pay less attention to comments from individuals that are essentially form letters in which the commenter fills in a few individual details and signs their name. Instead, the agency will be looking for more personal perspectives that bring each provider's insight on proposals.

APTA offers members and other supporters ways to easily participate in the comment process, but we've also introduced new resources that make it easy to create truly individualized comment letters that land with CMS.

Next steps: Instructions on writing a comment letter and tips on how to create maximum impact with minimal effort are available now. In addition, APTA's standard template comment letter — a prewritten format that is partially customizable — is also available. Both resources can also be accessed through the APTA Regulatory Action Center.

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