Proposed Fee Schedule Rule Wrestles With PTA, OTA Services Delivered 'In Part'; Includes Changes to MIPS

Despite serious questions and criticisms from APTA, the American Occupational Therapy Association (AOTA), and other stakeholders, the US Centers for Medicare and Medicaid Services (CMS) intends to move ahead with its plans to require providers to navigate a complex system intended to identify when therapy services are furnished by a physical therapist assistant (PTA) or occupational therapy assistant (OTA). The approach, which in 2022 would trigger a payment differential depending on how many minutes of services are provided by a PTA or OTA, is included in the proposed 2020 physician fee schedule rule released by CMS on July 29.

As always, the physician fee schedule (PFS) rule is an extensive document that covers a wide range of providers and settings, with an emphasis on individual provider payment rates. But for the physical therapy profession, the big story for the 2020 proposed rule is related to how CMS plans to require providers to comply with a law requiring identification of services furnished "in whole or in part" by a PTA or OTA. The approach being contemplated by CMS—to set a "de minimis" 10% bar—has been criticized by APTA as one that has "serious implications for beneficiary access to care," particularly in rural and underserved areas.

The proposed 2020 rule would require the new PTA and OTA modifiers (CQ and CO, respectively) to be included in claims beginning January 1, 2020, with a payment differential implemented in 2022. CMS also proposes to add a requirement that the treatment notes explain, by way of a short phrase or statement, why the modifier was or wasn't used for each service furnished that day. In short, the system is rooted in minutes of service, and would require the use of the applicable modifier that would indicate when a PTA or OTA provided outpatient therapy services for 10% or more of the total time spent furnishing the service.

And yet, as most physical therapists (PTs) and occupational therapists (OTs) well understand, the provision of therapy services isn't quite that simple. Questions start to pile up fairly quickly: what if the PTA or OTA services are provided concurrently with the PT or OT? What if the PTA or OTA services are administrative or nontherapeutic? What about group therapy? How is time designated when delivering supervised modalities?

CMS attempts to anticipate these and other potential complications by making a few definitive decisions—for instance, administrative or nontherapeutic services provided by a PTA or OTA that could be provided by others without PTA or OTA education and training don't count—and providing examples of how the time allotments would be calculated in various scenarios.

Despite the extensive requirements and explanations (and accompanying charts), a CMS fact sheet on the proposed fee schedule states that the system imposes "the minimum amount of burden for those who bill for therapy services while meeting the requirements of the statute."

APTA disagrees with that assertion, and has voiced additional concerns about how the system would impact patient access to care. While acknowledging that CMS is bound by law to create a PTA modifier, the association takes issue with CMS’ interpretation of “in part,” and asserts that the agency's attempt to quantify what "in part" means is excessively complex, discounts the role of the therapist, and exceeds the intent of the law. That mischaracterization of the law, APTA argues, will quickly lead to confusion and loss of access to care, particularly among beneficiaries in and underserved rural areas.

APTA plans on continuing its advocacy for a less complex, more patient-friendly system, including lobbying federal legislators to take a closer look at the plan and seeking meetings with CMS. APTA also will provide comments on the PTA/OTA modifier plan and other elements of the proposed fee schedule by the September 27, 2019, deadline, and will create a customizable template letter, available on APTA's Regulatory Action webpage, for individual provider comment.

Here are other highlights of the proposed rule:

Payment would increase slightly
CMS estimates that the 2020 conversion factor would be $36.0896, just about a nickel more than 2019's $36.04.

MIPS measures and performance thresholds for PTs and OTs would change—and CMS is looking at ways to make things less complex
The proposed rule would add measures for diabetes mellitus neurological evaluation, diabetes mellitus evaluation of footwear, screening for depression and follow-up plan, falls risk assessment, falls plan of care, elder maltreatment screen and follow-up plan, tobacco use screening and cessation intervention, dementia cognitive assessment, falls screening for future falls risk, and functional status change for patients with neck impairments. The rule also removes 2 measures: pain assessment and follow-up, and functional status change for patients with general orthopedic impairments.

Additionally, CMS has proposed that MIPS-eligible clinicians with a final score of 45 would receive a neutral payment adjustment, a change that CMS believes will lead to more clinicians receiving positive adjustments than negative ones. The current neutral payment adjustment score is set at 30.

CMS is also proposing the concept of shifting to a streamlined version of MIPS, which it has dubbed "MIPS Value Pathways," (MVPs) for 2021 and beyond. According to CMS, the MVP system would help providers align activities across the 4 existing MIPS categories by specialties or conditions. MVPs would focus on population health priorities and reduce reporting burden by limiting the number of required specialty- or condition-specific measures so that all clinicians or groups reporting on a clinical area would report the same set or sets of measures. The change would also provide more data and feedback to clinicians, which in turn "helps clinicians quickly identify strengths in performance as well as opportunities for continuous improvement," according to a CMS press release on the proposed rule.

It's not a "limitation," it's a "threshold amount"
In a change that adds semantic reinforcement to the end of a hard cap on therapy services established in 2018, the proposed rule clarifies that the dollar amounts assigned to therapy services aren't limitations per se, but "threshold amounts" that, when exceeded, require the KX modifier. In turn, the KX modifier would be regarded as confirmation that the additional services are medically necessary. CMS also says it will clarify regulations on the medical review threshold and the applicable years for the targeted medical review process

New dry needling codes, and changes to codes and RVUs for biofeedback
The American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel approved 2 new CPT codes to report dry needling of musculature trigger points in 2020. These codes, with proposed relative value unites (RVUs) of .32 (205X1, needle insertion without injection, 1 or 2 muscles) and .48 (205X2, needle insertion without injection, 3 or more muscles), were surveyed and reviewed by the Health Care Professions Advisory Committee, a group of non-MD/DO health professionals, including a PT representative. Those new codes are included in the proposed PFS.

Also, in September 2018, the AMA CPT Editorial Panel replaced CPT code 90911 (Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) with 2 new codes to describe biofeedback training initial 15 minutes of 1-on-1 patient contact and each additional 15 minutes of biofeedback training.

As a follow-up to another CPT editorial panel decision in 2018 that replaced a single CPT biofeedback code with 2 separate codes, CMS is also proposing an RVU of 0.90 for CPT code 908XX (biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry when performed; initial 15 minutes of one-on-one patient contact) and 0.50 for code 909XX (biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry when performed; each additional 15 minutes of one-on-one patient contact). The proposed rule also designates the 2 codes as “sometimes therapy” procedures, meaning that an appropriate therapy modifier is always required when this service is furnished.

Intensive cardiac rehab (ICR) would be expanded
CMS is proposing that coverage for ICR, which tends to be more structured, rigorous, and integrative in its emphasis on diet and cognitive-behavioral factors, be expanded to beneficiaries with stable chronic heart failure. It's also looking to expand coverage for both ICR and cardiac rehabilitation to other cardiac conditions as identified through a national coverage determination—providing that determination finds clinical support for an expansion.

CMS is looking for comments on bundled payments
Can concepts and principles associated with bundled payment models—particularly the idea of per-beneficiary payments for multiple services or condition-specific episodes of care—be applied to the PFS? CMS believes it has the flexibility to implement bundling concepts in future rules, and is looking for public comment on the idea.

Want to hear more about the proposed fee schedule directly from the APTA experts? Be on the lookout for an upcoming special "Insider Intel" phone-in session exclusively devoted to the PFS in the coming weeks. We'll announce the date and time via PT in Motion News and social media.