Proposed Home Health Rule Moves Ahead With New Payment System, Allows Therapist Assistants to Furnish Maintenance Therapy

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.

Full story at APTA

CMS Promotes More Access to Nondrug Pain Management in Medicaid

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.

Full story at APTA

The More Things Change, the More They…Change: CMS Announcements Dominate Top PT in Motion News Stories for 2018

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.

Full story at APTA

APTA, Other Health Care Leaders Call for CMS to Rethink Evaluation and Management Payment Plan

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.”

Full story at APTA

Payers Looking for More Coding Detail

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.

Full story at APTA

Final Inpatient Payment Rule Increases ACH Payments by $2.4 Billion, Cuts LTCH Payments by $110 million

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.

Full story at APTA

New HHA Medicare, Medicaid Participation Requirements Won’t Launch Until January 2018

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.

Full story on CMS and HHAs participation requirements at APTA

CMS Clears Up Error in Description of Which CPT Code Combinations Won’t Receive Full Payment

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.

Full story of the new Current Procedural Terminology (CPT) tiered coding set at APTA

Inpatient Payment Proposed Rule Calls for $3 Billion Increase to Acute Care Hospitals, Reductions for Long-Term Care Hospitals

Acute care hospitals (ACHs) could receive a 2.9% increase in payment rates next year and see a relaxation in some reporting requirements related to electronic health records (EHRs) if a proposed rule from the Centers for Medicare and Medicaid Services (CMS) is rolled out as-is. The losers in the equation? Long-term care hospitals (LTCHs), which could face a 3.75% payment cut under the proposal.

The inpatient prospective payment system (IPPS) proposed rule released last week (CMS fact sheet here) covers a range of areas related to how ACHs and LTCHs would operate in relation to Medicare and Medicaid beneficiaries. Here are a few highlights of the proposed rule:

The proposed 2.9% ACH payment increase amounts to a $3 billion increase. Last year the increase was 0.95%.

Full story of new inpatient payment proposed rule at APTA

CMS Puts the Brakes on Unpopular ‘Pre-Claim’ Demonstration, Delays Conditions of Participation Update for Home Health

Good news for home health agencies (HHAs) and the physical therapists who work in those settings: the Centers for Medicare and Medicaid Services (CMS) is suspending its plans to expand a required pre-claim review process and is putting its sole demonstration on hold in Illinois for at least 30 days. The agency has also decided to hold off on implementing revisions to conditions of participation for HHAs.

The announcement from CMS arrived just as the agency was scheduled to include Florida as the second state in a 5-state audition of a system requiring HHAs to submit supporting documentation for services while beneficiaries are receiving care. The proposal was largely opposed by HHA organizations, who view the requirement as an excessive administrative burden. CMS announced the suspension on March 31, 1 day before HHAs in Florida were set to begin the pre-claim demonstration.

Full story of a required pre-claim review process at APTA