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It's official: the US Centers for Medicare and Medicaid Services (CMS) is proposing that physical therapist (PTs) join the list of providers who must participate in the CMS Quality Payment Program (QPP), which would mean that beginning in 2019 PTs providing services under Medicare Part B must participate in either the Merit-based Incentive Payment Program (MIPS) or an Advance Alternative Payment Model (APM).

But that's not the only significant change proposed by CMS. In a win for APTA and its members, the proposed rule would also eliminate functional limitation reporting (FLR), a requirement consistently opposed by the association.

APTA regulatory affairs staff are reviewing the proposed rule and will provide more detail in the coming weeks. Here are the major takeaways so far:

MIPS-eligible clinicians would include PTs
PTs, occupational therapists, clinical social workers, and clinical psychologists who furnish services under Medicare Part B would be added to the list of providers required to participate in the MIPS program or, alternatively, an approved APM as part of the QPP. Currently, PTs may voluntarily participate in the QPP; if the proposed rule is adopted, the program would begin for PTs in 2019.

MIPS requires reporting in 4 performance categories—quality, promoting interoperability, clinical improvement activities, and cost. Providers earn points in each category, producing a total annual MIPS score, which in turn determines whether the providers earn a payment incentive, remain neutral in payment, or be subject to a penalty. Several of the data points must be reported electronically through certified EHR vendors or registries such as APTA’s Physical Therapy Outcomes Registry. The inclusion of PTs comes as MIPS enters its third year of the program.

Goodbye FLR?
The FLR requirement, long-characterized by APTA as an unnecessary burden on PTs and other providers, would be eliminated under the proposed rule. Change or elimination of the FLR requirement was an ongoing target for the association, which provided data to CMS showing that the requirement didn't accomplish the value-based care goals that CMS envisioned.

Physical therapist assistant (PTA) differential officially established
Under the proposed rule, CMS would establish 2 new therapy modifiers to identify the services furnished in whole or in part by PTAs or occupational therapy assistants (OTAs) beginning. January 1, 2020. The change, mandated by the Bipartisan Budget Act of 2018, establishes modifiers to be used whenever a PTA or OTA furnishes all or part of any covered outpatient therapy service, and would set the stage for a planned payment differential that would reimburse services provided by PTAs and OTAs at 85% of the fee schedule beginning in 2022. CMS anticipates the creation of a voluntary reporting system for the new modifiers beginning in 2019.

Payment would get a slight increase
After applying adjustment factors mandated by the Bipartisan Budget Act of 2018, the proposed fee schedule conversion factor would be increased slightly, from $35.99 to $36.05.

KX modifier requirements remain
The permanent fix to the Medicare therapy cap enacted in 2018 included requirements to continue using the KX modifiers for claims that exceeded a threshold, which in 2018, is $2,010 for PT and speech-language pathology (SLP) services combined. CMS also references the targeted medical review process, noting the threshold amount of $3,000. That system would continue, but the proposed rule emphasizes that not all claims exceeding the threshold would be subject to review.

More alternatives to MIPS
Providers who elect to participate in the QPP through APMs would be allowed a bit more leeway in the new rule. For example, providers participating in the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration project would avoid MIPS reporting and payment adjustments if they participate in Medicare Advantage arrangements that are "substantially similar" to APMs.

"The proposed rule contains provisions that, while not unexpected, have some far-reaching implications for physical therapists," said Kara Gainer, APTA director of regulatory affairs. "APTA will be analyzing the proposed rule in more detail and providing more information as it becomes available."

The association will also be providing comments on the proposed rule by the September 10 deadline.


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