When it comes to Centers for Medicare and Medicaid Services (CMS) changes, I have come to believe that there are 3 sides of the story: the CMS version, the providers’ version, and the truth, which is usually somewhere in the middle. The Patient-Driven Groupings Model (PDGM) that will govern home health payment beginning January 2020 is a good example of what I’m talking about.
PDGM shook the therapy world when it was announced that the number of therapy visits will not be considered or weighed into each 30-day period pricing for home care within a 60-day episode. As usual, providers, fearful of losing money, started to lay off therapy staff without really understanding what CMS intended.
Most of us understand that therapy visit thresholds were used to determine the additional pricing to the base rate for a home care 60-day episode. Home health providers have paid particular attention to this fact, realizing that the number of therapy visits at certain thresholds adds value to the base amount of the home care episodic rate. Back when the therapy threshold was 10 visits, home care agencies tried to have a minimum of 10 visits to capture that dollar amount. When the threshold increased to 13 visits, that number soon became the norm of therapy visits for every patient. Later, the therapy threshold moved to 19 visits. Home care agencies started to add multiple therapy services to attain that number and discharged every patient after 19 visits.
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.
According to the Centers for Disease Control and Prevention, emergency departments treat 3 million older adults for falls each year. More than 800,000 patients are hospitalized after a fall, approximately 20% of falls result in serious injuries, and falls are the second leading cause of accidental or unintentional injury deaths worldwide. Despite these often preventable statistics, individuals enrolled in Medicare often are not screened for risk of falling at their annual wellness visit.
Currently, during the initial annual wellness visit, a provider is required to assess an individual’s functional ability and level of safety with regard to the ability to successfully perform activities of daily living, falls risk, hearing impairment, and home safety. However, the Centers for Medicare and Medicaid Services (CMS) does not require functional status and safety assessments in follow-up wellness visits, in part due to the fact that the United Stated Preventative Services Task Force (USPTSF) has not proffered a recommendation for such.
In a final rule from the US Centers for Medicare and Medicaid (CMS), inpatient rehabilitation facilities (IRFs) will see a 2.5% payment increase in the 2020 fiscal year (FY), which begins October 1, 2019—an approximate boost of $210 million. But they’ll also need to prepare for some expanded reporting measures in the years to come—including a requirement to report data on social determinants of health.
Reporting requirements won’t change much in FY 2020. However, beginning with the FY 2022 IRF Quality Reporting Program (QRP), IRFs will be required to provide certain standardized patient assessment data (SPADE) to CMS. The additional SPADE requirements are aimed at bringing IRFs up to speed with provisions of the 2014 IMPACT Act, a law that mandated more uniformity in reporting across postacute care (PAC) settings. In a fact sheet on the final rule, CMS writes that the addition of these SPADES “will improve coordination of care and enable communication.”
Specifically, CMS will adopt the SPADES on pain interference on sleep, therapy, and day-to-day activities, provisions being added in light of the opioid crisis. CMS is considering adding future SPADEs including dementia, bladder and bowel continence, care preferences, advance care directives and goals of care, caregiver status, veteran status, health disparities and risk factors, and sexual orientation. Also on CMS’ radar: assessments related to opioid use, and frequency, exchange of electronic health data, and interoperability.
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.
Not all rehabilitation is equal for acute care hospital patients with ischemic stroke, say researchers in an article published in the May issue of PTJ (Physical Therapy). Authors found “significant variation” in the use of hospital-based rehabilitation services that “suggest a timely opportunity to standardize rehabilitation service delivery in acute settings for patients with ischemic stroke.”
While current guidelines recommend early mobilization during hospitalization for ischemic stroke, authors write, they do not “provide clear recommendations on the optimal dosage of therapy.” This, combined with no incentive for hospitals to report on functional status to the US Centers for Medicare and Medicaid Services (CMS), led researchers to examine Medicare claims data from 104,295 patients in 2010 to identify what factors were associated with the type and amount of rehabilitation services patients received while in acute care settings.
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.
Sure, the biggest news from the 2019 Medicare physician fee schedule is the new reporting and payment system for many physical therapists (PTs), but that’s not the whole story: the 2019 rule also includes new current procedural terminology (CPT) codes that allow PTs to conduct and bill Medicare for remote monitoring of patient factors such as weight, blood pressure, and pulse oximetry.
Many questions remain as to how the US Centers for Medicare and Medicaid (CMS) will implement the new codes, and APTA is developing online resources that will supply further details as they become available.
Here’s what APTA knows so far: the new CPT codes apply to chronic care, and they allow physicians, clinical staff, or “other qualified healthcare professionals” to conduct remote monitoring in certain circumstances. Because PTs are included in the American Medical Association’s definition of “qualified healthcare professionals” they are able to participate in the remote monitoring to the extent allowed by state and scope-of-practice laws.
As it continues to roll out final payment rules for 2019, the US Centers for Medicare and Medicaid Services (CMS) is sticking to its pattern of mostly following through on its original proposals—this time by ending payment rates that favor hospital-owned outpatient facilities over independent physicians’ offices, and adopting a new supplier bidding system for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS).
Outpatient Prospective Payment System (OPPS)
As it proposed, CMS will expand the use of a “site-neutral” payment model in its reimbursement for the clinic visit service (HCPCS G0463), the most common service billed under the OPPS. Currently, Medicare and beneficiaries often pay more for the same type of clinic visit in the hospital outpatient setting than in the physician office setting. CMS is doing away with the current system that pays so-called “off-campus” hospital-owned facilities an estimated $75 to $85 more than it does independent counterparts for this service. According to a CMS fact sheet, the agency estimates that the change, implemented over a 2-year period, will save an estimated $380 million in 2019 alone. The change does not directly affect physical therapists (PTs) working in outpatient hospital settings, given that outpatient therapy services delivered by PTs are paid under the physician fee schedule, not OPPS.