Scrutinizing Medicare coverage for physical, occupational and speech therapy

For years, confusion has surrounded the conditions under which older adults can receive physical, occupational and speech therapy covered by Medicare.

Services have been terminated for some seniors, such as those with severe cases of multiple sclerosis or Parkinson’s disease, because therapists said they weren’t making sufficient progress. Others, including individuals recovering from strokes or traumatic brain injuries, have been told that they reached an annual limit on services and didn’t qualify for further care.

Neither explanation stands up to scrutiny. Medicare does not require that older adults demonstrate improvement in order to receive ongoing therapy. Nor does it limit the amount of medically necessary therapy, for the most part.

Full story at news-medical.net

Lifting therapy caps proves a load off Medicare patients’ shoulders

Beers, a retired railroad engineer who lives outside Sacramento, Calif., has a form of Parkinson’s disease. The treatments slow its destructive progress and “he will need it for the rest of his life,” Morse said.

But under a recent change in federal law, people who qualify for Medicare’s therapy services will no longer lose them because they used too much.

“It is a great idea,” said Beers. “It will help me get back to walking.”

Full story at News Medical

Therapy Cap Breakthrough? Legislators Reach Bipartisan Agreement on Repeal

After 20 years of opposition from APTA and 17 years of 11th-hour congressional patches to an inherently flawed policy, the Medicare therapy cap may be on its way out for good.

But nothing’s certain yet, and there are many details still to be worked out.

On October 26, APTA representatives attended a meeting on Capitol Hill during which lawmakers from the House Energy and Commerce Committee, the House Ways and Means Committee, and the Senate Finance Committee announced a bipartisan agreement to end the therapy cap. The road from proposal to actual repeal can be long, and success isn’t guaranteed, but if the proposal survives, it would represent a major victory for patients and the physical therapy profession.

Full story at APTA

Study: CMS Should Pay Closer Attention to Chronic Wounds

In its push toward outcomes-based models, the US Centers for Medicare and Medicaid Services (CMS) needs to take a closer look at wound care, say authors of a new study that estimates nearly 15% of all Medicare beneficiaries experience chronic nonhealing wounds at an annual cost of nearly $32 billion. And the researchers believe those numbers are on the conservative side.

The study, recently published in Value in Health, analyzed data from Medicare’s 5% Limited Data Set during 2014 for details on claims in which wounds were the primary or secondary diagnosis. Researchers looked at costs, both in aggregate and by care setting, for 12 types of wounds: arterial ulcers, diabetic foot ulcers, diabetic infection, chronic ulcer, pressure ulcer, skin disorders, skin infection, surgical wounds, surgical infection, traumatic wound, venous ulcers, and venous infection. Here’s what they found:

  • In 2014, approximately 14.5% of Medicare beneficiaries were diagnosed with at least 1 type of wound or wound infection—that’s about 8.2 million patients.

Full story at APTA

Study Says Cost Savings of Physical Therapy for LBP Are Significant

When it comes to physical therapy for treatment of low back pain (LBP), Medicare is getting a bargain, according to authors of a new study. Researchers say that not only is physical therapy cheaper than injections or surgery in the short-term, it’s an approach that is likely to save on treatment costs for at least a year after initial diagnosis, with average savings of 18% over treatments that begin with injections and 50% over treatments that begin with surgery.

The study, commissioned by the Alliance for Physical Therapy Quality and Innovation (APTQI), focused on Medicare A and B claims data from 472,000 beneficiaries who received a diagnosis of LBP and began treatment between February and October of 2014. Researchers from the Moran Company tracked 3 treatment paths—physical therapy, injections, and surgery—and compared total costs of initial treatment as well as total costs for 12 months after diagnosis. The study also included an analysis of cost differences associated with how soon physical therapy was initiated after diagnosis, the physical therapist interventions used, and relationships between the use of physical therapy and the referring health care provider.

Full story at APTA

Proposed Medicare Fee Schedule Maintains—and Sometimes Increases—Payment for Codes Related to Physical Therapy

No cuts. And even a few increases.

That’s the major takeaway from the proposed Medicare 2018 physician fee schedule released by the US Centers for Medicare and Medicaid Services (CMS). It’s a plan that settles questions about potentially “misvalued” current procedural terminology (CPT) codes by generally accepting work relative value units (RVUs) that had been proposed by an American Medical Association (AMA) advisory committee that worked closely with APTA.

Under the proposed fee schedule, 13 of 19 CPT codes frequently used by physical therapists (PTs) will retain their 2017 RVUs, with the remaining 6 seeing slight increases. Additionally, RVUs for 2 codes associated with the management and training of patients with orthotics or prosthetics were increased, and a new code was added (977X1, intended for use on a “subsequent encounter” or different date of service from the initial encounter).

Full story of Medicare payment codes related to PT at APTA

Two New Bills in House Focus on Expanding Telehealth in Medicare, Opening up Possibilities for PTs

Medicare could become a much more welcoming place for telehealth services if Congress passes 2 pieces of legislation recently introduced in the US House of Representatives. The 2 separate bills would have the combined effect of expanding where and how telehealth services can take place, which patients are permitted to receive the services, and the list of health care professional who can provide the services—a list that includes physical therapists (PTs).

The bills—1 called the Medicare Telehealth Parity Act, and a second known as the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act—propose changes to the way Medicare handles a number of issues, from remote monitoring of patients with chronic conditions, to a reworked definition of reimbursable telehealth codes. In addition, the parity act expands the list of providers who can provide telehealth services to PTs, respiratory therapists, occupational therapists (OTs), speech language pathologists, and audiologists, while the CONNECT act would allow PTs in some bundled payment arrangements, accountable care organizations (ACOs), and Medicare Advantage plans to participate in telehealth arrangements.

Full story of expanding telehealth in Medicare at APTA

‘Locum Tenens’ for PTs Set to Begin in June

It’s official: starting June 13, physical therapists (PTs) in certain areas will be able to bring in another licensed PT to treat Medicare patients during temporary absences for illness, pregnancy, vacation, or continuing medical education, and bill Medicare for the services. And just as the new provisions begin, the old term for the concept—”locum tenens”—will be discontinued, according to the Centers for Medicare and Medicaid Services (CMS).

In a transmittal published May 12, CMS announced that “reciprocal billing and fee-for-time arrangements” under Medicare part B will be extended to PTs in health professional shortage areas (HPSA), medically underserved areas (MUA), or in CMS-designated rural areas (any area outside of a Metropolitan Statistical Area or Metropolitan Division). The change, triggered by the passage of the 21st Century Cures Act signed into law in December 2016, was 1 of APTA’s top public policy priorities.

Full story of locum tenens for PTs at APTA

Bill Introduced in House Would End Physician Self-Referral Loophole for Physical Therapy

Medicare self-referral loopholes—the exception that allows physicians to refer patients for physical therapy and other services to a business that has a financial relationship with the referring provider—is once again in the legislative spotlight on Capitol Hill.

On April 6, the Promoting Integrity in Medicare Act (PIMA) was reintroduced in the US House of Representatives (HR 2066), in hopes of eliminating the exception to the federal law originally intended to prohibit self-referral. That law, known as the Stark law, does prohibit most self-referral practices, but it also contains language that allows physicians to self-refer for “patient convenience” or same-day treatments—known as in-office ancillary services. Unfortunately those exceptions also include services that are rarely provided on the same day—physical therapy, anatomic pathology, advanced imaging, and radiation oncology.

Full story of the Promoting Integrity in Medicare Act at APTA

Analysis of Hospital System’s LE Joint Replacement Bundling Programs Reveals Significant Drop in Expenditures

In brief:

  • Analysis of Medicare payments related to 3,942 LE joint replacements in a 5-hospital network participating in voluntary bundling programs between 2008 and 2015.
  • During study period, average expenditures on replacements without complications dropped by 20.8%; expenditures on replacements with complications dropped by 13.8%.
  • Treatment population, severity of illness, and outcomes remained stable during study period; volume rose steadily.
  • Just over half (50.2%) of the savings were related to reduced in-hospital costs—predominantly due to a 30% reduction in the cost of implants. The remaining 48.8% of savings were related to a decreased use of IRFs and SNFs.
  • Use of home health care (including physical therapy in that setting) increased by 9% during study period.

It may be too soon to judge the cost-effectiveness of Center for Medicare and Medicaid Services’ (CMS) mandatory hip and knee replacement bundling programs, but if the experience of 1 hospital system that participated in earlier voluntary programs is any indication, facilities have reason to expect overall Medicare expenditures to drop, say authors of a new study. Their analysis of nearly 4,000 patients who participated in bundling programs between 2008 and 2015 revealed an average 20.8% reduction in expenditures for joint replacements without complications, with the bulk of those savings due to reduced implant prices and the decreased use of institutional postacute care.

Full story on the cost-effectiveness of hip and knee replacement bundling programs at APTA