On the PTA Payment Battleground, We Are All APTA
By David Harris, PTA, MBA
I was working as a physical therapy technician when Congress instituted the Medicare cap on therapy services on January 1, 1999. I was to graduate as a physical therapist assistant (PTA) in May of that year, and, at that time, I had no idea or even much concern about what the cap would mean for our profession or my career.
I heard horror stories about layoffs of physical therapists (PTs) and PTAs due to the payment changes, but as a new graduate I was focused solely on finding a job in my chosen profession. It was not until years later, when I began working in outpatient care and seeing problems with payment, that I realized the importance of getting involved with advocacy.
Since that time, I have been as engaged as possible at the local, state, and national levels to be part of the solution to problems that arise for our profession, including payment for the services that we provide to our patients on a daily basis.
The therapy cap was part of the advocacy conversation for nearly 2 decades, but then, in 2018, there was a breakthrough: years of advocacy by APTA staff and members, as well as colleagues in other health professions, finally ended the permanent cap when the Bipartisan Budget Act of 2018 repealed it and replaced it with thresholds above which claims must include the KX modifier to indicate that services are medically necessary as justified by the documentation.
The repeal was a win, but it also created a challenge with regard to PTA services and payment: Beginning on January 1, 2020, outpatient therapy providers are required to use a CQ or CO modifier to denote when outpatient therapy services are furnished in whole or in part by a PTA or occupational therapy assistant. Starting in 2022, Medicare payment for these outpatient therapy services—as identified by the CQ or CO modifier—will be paid at 85% of the physician fee schedule (PFS) in effect for each year. The reduced payment rate applies to therapist services in private practice, outpatient hospitals, rehab agencies, skilled nursing facilities, home health agencies, and comprehensive outpatient rehab facilities.
These policy changes pose significant threats to patient access to quality care and to the overall viability of many practices throughout the country. Accordingly, APTA, along with several other stakeholders, began working with the Centers for Medicare and Medicaid Services (CMS) to ensure that the agency interpreted and implemented the policy in a manner that complies with the law's intent but imposes as little harm as possible to our patients and to clinicians.
During the remainder of 2018, APTA met with CMS in person and over the phone and submitted extensive comments in response to the 2019 PFS proposed rule that included CMS' definition of "in whole or in part." In all of the communications with CMS, including extensive comments in response to the 2019 PFS proposed rule, APTA put forward recommendations regarding how to define when services are furnished "in whole or in part."
In the 2019 PFS final rule, along with clarifying how CQ and CO modifiers would be used, CMS finalized a 10% "de minimis" standard under which a service is considered to be furnished in whole or in part by a PTA or OTA and thus require the modifier. APTA engaged in additional dialogue with the agency to help shape CMS’ implementation of the 10% de minimis standard in 2020 rulemaking.
When CMS published the 2020 Medicare PFS proposed rule this summer, the guidance on how it would apply the 10% de minimis standard immediately caused APTA and its members to have concerns. The proposed application was not only complex, it also was fundamentally flawed and would result in drastic underpayments for outpatient therapy services. One of our primary concerns was that, if the policy was finalized as proposed, CMS would be creating an access issue for Medicare beneficiaries.
Subsequently, APTA, along with several other associations, arranged an in-person meeting with CMS Administrator Seema Verma to discuss concerns with the proposed implementation. Representatives from APTA, the American Occupational Therapy Association, the American Speech-Language-Hearing Association, and the National Association for the Support of Long-Term Care attended the meeting and voiced our concerns. The meeting was the first time that APTA had been able to meet directly with Administrator Verma on this specific issue. Administrator Verma listened to our concerns and asked several questions on how this new rule would affect our patients and clinicians going forward. I felt like we were able to drive home the points of the increase in administrative burden with the new modifiers, as well as our significant concerns that the 15% reduction would limit patient access to care across the country, especially in rural and medically underserved areas of the country. This same sentiment was echoed in thousands of comments submitted by the physical therapy profession in response to the proposal.
Our collective efforts made a huge impact in the 2020 final rule: The CQ modifier will not be required when PTs and PTAs deliver services jointly (as when the PTA provides skilled services alongside the PT rather than separately from the PT), the de minimis standard will be applied to each unit of service, defined in a 15-minute increment, rather than to the total PT and PTA time spent furnishing the services, and the proposed documentation requirements were not adopted.
The take-away: We as clinicians have to get involved and stay involved. I have seen many comments about how the association has let us down on this issue. But, quite honestly, we—clinicians and students—are APTA, so we are ultimately responsible for being the "boots on the ground" for the association and the profession.
The battle for quality health care and appropriate payment for physical therapy services will probably never end, but it is vital that all of us in the profession understand that if we want to see positive change, we are the ones who can and must stand up and voice our concerns to our local, state, and federal legislators. I urge every clinician and student to reach out to their state and federal legislators regarding current and future proposed changes.
David Harris, PTA, MBA, is vice president of integrations at Upstream Rehabilitation and chief delegate of the PTA Caucus.
Got MIPS Questions? We Have Answers.
The Merit-based Incentive Payment System (MIPS) is now in effect for many physical therapists. At a recent live webinar, APTA answered some of our members' most pressing questions. (In case you missed it, you can listen to the recorded webinar in its entirety.)
We've recapped some popular questions here. Not finding the question you need answered? You can email firstname.lastname@example.org. APTA members can also post questions, and review answers to other member questions on the Medicare MIPS Discussion Board on the Medicare Quality Reporting Hub.
What is the quickest way to find out if my practice is required to participate?
The Centers for Medicare and Medicaid Services (CMS) website has an easy lookup tool. Just type in your national provider identifier (NPI) number and you'll see whether you are required to participate as a practice, or as an individual.
APTA's MIPS resource page has a lot of information, including a decision tree to help you understand MIPS eligibility and required vs voluntary participation.
In brief, you must participate if you are an individual PT in private practice and exceed all 3 criteria for the "low-volume threshold":
- Receive more than $90,000 in Medicare part B payments each year
- Provide care for more than 200 Part B-enrolled Medicare beneficiaries annually
- Bill more than 200 professional services annually
My small practice is going to participate in MIPS. Because we have fewer than 15 PTs, we are allowed to report via claims instead of through a registry or QCDR. What are the business considerations for choosing one method or the other? Can we switch from claims to registry reporting later, or are we stuck with whatever choice we make?
If you report via claims, you can submit your quality data on your claim form. However, you will not get feedback on your performance until after the end of the reporting year, when it will be too late to make changes that could help your MIPS score. Even though you will incur a cost using a registry, it will provide you with feedback throughout the year. The type and frequency of feedback may vary by registry. You can switch data submission methods mid-year. CMS will base your score on your top 6 measures.
Does MIPS apply to hospital-based outpatient practices?
No. For 2019, if you practice in a facility-based setting such as a hospital outpatient department, skilled nursing facility (part B), or rehabilitation facility you are not able to participate in MIPS.
Our physical therapy clinic is part of a multispecialty practice in which the physicians already report as a group. The PTs do not meet the low-volume threshold as individuals. Do we need to report as part of the group?
It may depend on your specific multispecialty practice. You can contact us at email@example.com to address your questions.
We have 6 PTs in our practice, and none of them exceed the low-volume threshold individually. But as a group, we do. Do we have to report?
The group is not required to participate, since MIPS only mandates individual PT participation. However, because the practice as a whole exceeds the threshold, it can choose to participate in MIPS to take advantage of the potential 7% incentive payment.
Our practice exceeds the threshold, but only 1 of our PTs does individually. How does that work?
You have 2 options: The PT participates alone, or the practice can participate as a group. Only the PT who exceeds the threshold is required to participate. However, because the whole practice also exceeds the threshold, it can participate in MIPS. If you choose group participation, all therapists will be considered fully participating in the program.
What are my options for reporting improvement activities? Do you have recommendations?
CMS offers over 100 improvement activities, which can be found on the CMS QPP website. APTA has created a condensed list of activities that may appeal to PTs.
How can we follow our performance scores to tell if we are meeting expectations throughout the year?
This is a great question. If you report via claims, you will not know your score until the end of the reporting year. This is why APTA recommends using a vendor for reporting. It can help you improve your scores throughout the year. If you report using a "qualified registry," check with your vendor to see how frequently you will be able to get feedback. Some may only be quarterly or monthly.
As a qualified clinical data registry (QCDR), APTA's Physical Therapy Outcomes Registry gives you continual real-time feedback.
If you are attending CSM, Heather Smith, PT, MPH, APTA director of quality, and Kara Gainer, JD, director of regulatory affairs, will be presenting "Emerging Issues in Medicare: Quality Programs and Alternative Payment Models" on Friday at 11:00 am, where a CMS representative will be available to address attendees' questions. Heather Smith also will host a Q&A session at 2:00 pm on both Thursday and Friday at the Physical Therapy Outcomes Registry booth #1433 in the Exhibit Hall.
CSM Preview: All You Ever Wanted to Know About MIPS
By Kara Gainer, JD
Value. Quality. Outcomes. Costs. The United States is moving away from the traditional fee-for-service reimbursement structure, one in which providers are rewarded solely for the volume of services provided, to one that holds providers accountable for patient outcomes and costs.
Beginning January 1, 2019, the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP), which offers incentive payments to help eligible clinicians focus on care quality and making patients healthier, will include many physical therapists who participate in Medicare Part B.
While we estimate only about 5% of Medicare-enrolled physical therapists in private practice will be mandated to participate or face a penalty, almost all physical therapists in private practice will be eligible. Considering that there are no more scheduled payment updates to the Medicare physician fee schedule after 2019, QPP participation is something you should seriously think about if you're one of those eligible PTs.
At APTA's Combined Sections Meeting in January, we will answer your most pressing questions about QPP:
- What do these acronyms mean?!
- How does it work?
- If I am not required to participate, what is the benefit to me if I do?
- What is the difference between the Merit-based Incentive Payment System (MIPS) and an Advanced Alternative Payment Model (APM)?
- How can I maximize my incentive payment?
Nothing is simple when it comes to Medicare, and QPP is no different. The devil is in the details—and there are a lot of them.
APTA Director of Quality Heather Smith, PT, MPH, and I will be diving into the nitty gritty of what physical therapists need to know if they want to successfully participate in QPP, whether through MIPS or Advanced APMs.
You may be asking yourself: "Do I really need to attend this session?" Well, here is what one California PT who attended a similar session on Medicare payment said:
So, if you're ready to get out of your comfort zone and transform your practice, join us on Friday, January 25, in downtown Washington, DC, for "Emerging Issues in Medicare: Quality Programs and Alternative Payment Models," where you will learn more about QPP and how you can participate in Medicare payment models that reward value over volume, achieving better patient outcomes.
CSM advance registration discounts end December 5.
Kara Gainer, JD, is APTA's director of regulatory affairs. You can connect with Kara on Twitter at @karagainer.
7 Things You Need to Know About Value-Based Care
Whether you love it, hate it, or still don't completely understand it, value-based care is here to stay. We've put together a brief explainer to clarify the what, how, and why of value-based care. (For a more in-depth discussion, check out APTA's podcast series.)
Value = Health outcomes achieved / Dollars spent. Changing the payment paradigm from volume to value forces greater efficiency in the health care system; that is, delivery of the highest quality of care, and the best outcomes, at a controlled cost. Implementing a payment structure that examines outcomes and cost also will drive better-informed decisions by the patient, the payer, and the clinician.
Value-based care is NOT fee-for-service. Value-based care shifts from payment solely based on the volume of care, such as traditional fee-for-service, to payment more closely related to outcomes of care. Value-based payment models use measures of quality and cost to determine payment to providers. These models also can be referred to as alternative payment models, or APMs.
It's all about collaboration. APMs incentivize collaboration among members of the health care team to achieve high-quality, cost-effective care.
Value-based care is not just for Medicare patients. Although 1 of the models PTs may be most familiar with is the Medicare comprehensive care for joint replacement (CJR) model, it is not the only model out there. There is a desire by all payers to move in this direction.
Data collection is critical to success. To complete the value equation, outcomes must be quantified through the use of patient-reported outcomes measures or performance-based measures. This is 1 reason the Physical Therapy Outcomes Registry is so important—it will allow much broader data collection than any 1 EHR product.
PTs should consider getting involved sooner rather than later. You will need to understand your practice and the patients you serve to decide when to participate in an APM and which model might work best. It could be a condition- or disease-specific model, such as joint replacement bundled care, or it may be population-based, such as an accountable care organization. Opportunities also may arise with specific payers.
The details matter. No 2 APMs are the same. If you decide to participate in an APM, you will need to contract with the model organizer (or convener). Contracting is a critically important step, because you will have to negotiate the amount of risk you are willing to take on the possible financial reward you could achieve.
Want to learn more? Listen to the full podcast series. You also can check out "Quality Measures That PTs Can Impact" on the APTA website.
The Road Less Traveled
By APTA President Sharon L. Dunn, PT, PhD, OCS
Anyone delivering care in the current environment can see the evidence of change ahead. We know that care delivery in a few years—even later this year—will look vastly different from how it looks today.
In fact, some changes are already here. Medicare will flip the switch on its Comprehensive Care for Joint Replacement Model (CJR) on April 1. Providers serving patients with TKA or THA in 67 US regions will be impacted by this collaborative bundled care model, which will change the way providers, including PTs, are paid. And that is just the beginning.
So, why the drive toward change in health care? It's all about the value-vs-volume equation. Payment decisions are rightly being driven by how to provide value-based care to our patients, rather than by the volume of services provided. It's a change we sorely need.
We can't—and often shouldn't—oppose change, but we can—and should—be involved in advocating for our profession as a part of the change. That's not always a clear path. Deciding which road to travel involves a lot of planning and strategy, with the hope that the environment also delivers a healthy side of opportunity that we can seize.
Of course, seizing opportunity to move the profession forward, to aid our transformation, isn't without risk. But there's an even greater risk: not acting and having someone else decide our path. That's the philosophy that drives APTA to take a proactive approach to payment reform and, more specifically, toward working with collaborators among our members and other provider stakeholders to reform the way physical therapists code services.
So let's keep thinking about how we can position ourselves for the long-term changes, but let's also prepare for the changes at hand, especially the 2 big changes coming this year. We want to make sure you are ready. First, make sure you understand what the CJR is and how it will affect you. Second, educate yourself on the new evaluation codes coming January 1, 2017, and the thinking (and process) behind their creation. Here are some resources that can help:
Health care is evolving, and our profession has a transformational vision. That's a lot of change to keep up with. But I know this profession and this association, and I'm sure that in partnership with one another, we can take on the road before us.