The Centers for Medicare and Medicaid Services (CMS) spends much of its spring and summer churning out regulatory rules for the coming fiscal and calendar years. That means it’s an equally busy time for APTA, its members, and other stakeholders to stay on top of the proposals, respond to whatever challenges emerge, and advocate for change when needed.
This year’s standout challenge: advocacy efforts around the CMS proposed physician fee schedule (PFS). The rule as proposed includes at least 2 troubling provisions that demanded a strong response—1 around how CMS would go about determining whether therapy services were delivered “in part” by a physical therapist assistant (PTA) or occupational therapy assistant (OTA), and another that proposes an estimated 8% cut to reimbursement for physical therapists (PTs) and several other professions.
APTA has been aggressively fighting these changes through comments, creating a platform to facilitate a flood of individual member letters to CMS, multiprovider organization sign-on letters, meetings with CMS representatives, and the latest: a bipartisan letter signed by 55 members of Congress urging CMS to rethink the cuts.
The big picture: An omnibus rule that could ease some regulatory burdens The US Centers for Medicare and Medicaid Services (CMS) has released a final rule aimed at reducing Medicare- and Medicaid-related regulatory burdens in a range of settings, from hospitals to home health care. And for the most part, the rule hits its target.
The final rule includes provisions related to outpatient rehabilitation facilities, home health agencies, ambulatory surgical centers, hospitals, CAHs, psychiatric hospitals, transplant centers, X-rays, community mental health clinics, hospice care, and more. For the most part, the changes either lift or relax requirements, giving facilities more leeway in meeting reporting and other duties. CMS estimates the changes will save providers 4.4 million hours of paperwork time and result in $800 million in savings annually.
The US Centers for Medicare and Medicaid Services (CMS) intends to go full steam ahead with its plans to shift to a new payment system for home health beginning in 2020. The plans are accompanied by other changes that include allowing maintenance therapy to be furnished by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs), providing a payment “add on” for rural home health care, and adopting an APTA-supported “notice of admission” requirement to avoid duplicate billing. The new provisions, which include a 1.3% payment increase, are included in CMS’ proposed rule released on July 11.
The biggest shift has been more than a year in the making: a transition to a new payment system known as the Patient-Driven Groupings Model (PDGM). The PDGM moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds from case-mix parameters. Instead, the system classifies 30-day care episodes according to a set of 5 major buckets and subsets within those buckets. Patients are assigned a status within the 5 major areas, and within some of those areas they can be assigned to more detailed clinical categories—the combination of categories assigned to a patient generates a particular case-mix grouping. APTA offers extensive information on the new system and will participate in a live August 5 webinar on the model jointly hosted by APTA, CMS, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association. APTA members can participate in this webinar.
Could states be doing more to increase access to nonopioid and nonpharmacological approaches to management of chronic pain under Medicaid? The US Centers for Medicare and Medicaid Services (CMS) thinks so, and has issued guidance that outlines options and shares examples of some states’ promising initiatives. The approaches are largely consistent with APTA’s #ChoosePTopioid awareness campaign, which emphasizes the importance of patient access and choice in the treatment of pain.
The CMS information bulletin released in late February is anchored in the US Centers for Disease Control and Prevention’s (CDC) guidelines for prescribing opioids for chronic pain, published in 2016. Those guidelines, which recommend nonopioid approaches including physical therapy as the preferred first-line treatment for noncancer chronic pain, have been increasingly acknowledged and adopted by state health care entities, and early reports are positive, according to CMS. The new CMS document is designed to help states understand possible avenues for incorporating programs that help support the CDC guidelines.
Looking back over 2018, it’s hard to overstate the magnitude of Medicare-related changes experienced by physical therapists (PTs), physical therapist assistants (PTAs), and their patients. It was a year that included the end of the hard cap on therapy services under Medicare and the announcement of the inclusion of qualifying PTs in its Quality Payment Program starting in 2019—a dramatic shift toward value-based payment. And did we mention the launch of new requirements for skilled nursing facilities (SNFs) beginning later in 2019?
While payment news is almost always of interest to PT in Motion News readers, keeping up with the US Centers for Medicare and Medicaid Services (CMS) was apparently top-of-mind in 2018, as Medicare-related stories dominated this year’s list of most-read News items.
APTA has joined with more than 150 other health care organizations to let the US Centers for Medicare and Medicaid Services (CMS) know that while its “Patients Over Paperwork” efforts are appreciated, one CMS attempt to reduce administrative burdens is likely to result in reduced access to care for some of the sickest Medicare beneficiaries.
The concerns center around a provision related to evaluation and management (E/M) visits included in the 2019 physician fee schedule rule proposed by CMS over the summer. The change, ostensibly intended to reduce paperwork, would collapse E/M payment rates currently based on a 5-level complexity system for new and established patients into what would amount to a 2-level system—combining levels 1-3 and levels 2-5. CMS acknowledges that the change would result in higher payments for E/M visits at the 1-3 levels while levels 4 and 5 will see reductions based on the 2019 proposed relative value units. However, CMS argues, the reduced paperwork burden would offset the payment drop.
In a letter sent to CMS last month, APTA and other cosigners praise CMS for its initiative to reduce provider paperwork, but question the wisdom of the E/M plan, arguing that the change would unfairly impact providers who see sicker patients, “ultimately jeopardizing patients’ access to care.”
Physical therapists (PTs), take note: the 59 modifier is a potential red flag for the US Centers for Medicare and Medicaid Services (CMS) and commercial payers.
The 59 modifier is the code under the health care common procedural code system (HCPCS) used to represent a service that is separate and distinct from another service it’s paired with. In an effort to tease out precisely why the service is distinct, CMS is requiring that in certain cases, providers use different modifiers instead of the 59 modifier. The modifiers—XE, XP, XS, and XU—are intended to bypass a National Correct Coding Initiative edit by denoting a distinct encounter, anatomical structure, practitioner, or unusual service.
When the X modifiers were introduced in 2015, PTs weren’t required to use them. But movement toward the use of these modifiers—and greater scrutiny of claims using the 59 modifier—is happening.
Acute care hospitals (ACHs) will receive a $2.4 billion increase in payment rates in 2018 and see a relaxation in some reporting requirements related to electronic health records (EHRs) under the final prospective payment system (PPS) rule issued by the Centers for Medicare and Medicaid Services (CMS) on August 2. The long-term care hospital (LTCH) situation isn’t as positive, however, with a projected 2.4% cut on the books for fiscal year (FY) 2018.
The inpatient prospective payment system (IPPS) final rule (CMS fact sheet here) covers a range of areas related to how ACHs and LTCHs will operate in relation to Medicare and Medicaid beneficiaries.
It’s now final: the US Centers for Medicare and Medicaid Services (CMS) has suspended startup of revised conditions of participation (CoP) for home health agencies (HHAs) until January 13, 2018. The new CoP originally were set to begin on July 13 of this year.
According to CMS, the updated minimum standards for HHAs that serve Medicare and Medicaid would strengthen patient rights, encourage more effective communication between patients and caregivers, and result in better outcomes reporting. HHAs had expressed concerns that they didn’t have enough time to prepare for the changes.
Apparently, physical therapists (PTs), occupational therapists (OTs), and the outpatient facilities they work for aren’t the only ones adjusting to the new Current Procedural Terminology (CPT) tiered coding set: recently, the Centers for Medicare and Medicaid Services (CMS) informed APTA that it’s revising its National Correct Coding Initiatives “procedure to procedure” edits, a long list of CPT code pairs that should not be reported together. That list of problematic paired codes included PT and OT evaluation and reevaluation codes.
It’s a complicated situation, but the bottom line is, CMS is making changes that should allow for full payment of PT and OT evaluation and reevaluations code combinations that previously resulted in erroneous payment denials or partial payment when the new code set was first adopted in January. Ironically enough, it appears the change is an attempt by CMS to correct an error in its National Correct Coding Initiative. Here’s a breakdown.