What began as a projected 9% cut in payment to PTs under Medicare and was later reduced to an estimated 3.6% cut may be whittled down even further thanks to a recently announced change to how payment is calculated. The change comes by way of an adjustment to the conversion factor, the multiplier applied to relative value units to determine Medicare Part B payment amounts. That figure changed from CMS’ planned $32.41 (precise number: $32.4085) rate to $34.89 ($34.8931) for 2021.

The new conversion factor is still a drop from the 2020 conversion factor of $36.09 ($36.0896), but one that’s far less severe than originally approved — a 3.32% decrease compared with the 10.2% reduction in the final fee schedule.

The result: The smaller cut, coupled with targeted provisions in a spending and COVID-19 relief bill enacted in late December, will help to blunt the effects of changes adopted by CMS that threatened to reduce physical therapy payment by an estimated 9%. Even before factoring in the changes to the conversion factor, the congressional action reduced the effects of the cuts from 9% to an estimated 3.6% for PTs.

How It Works Out for Payment

In some coding situations, the combination of factors may result in cuts less than the estimated 3.6%. For example, payment for therapeutic exercise (CPT code 97110) will drop by an average of 3.3%, from $31.40 in 2020 to $30.36 this year, with manual therapy (97140) seeing a similar percentage decrease, from $28.87 in 2020 to $27.91 in 2021. Neuromuscular reeducation (97112) drops by 2.35% (from $36.09 to $35.34), while CPT code 97530, for therapeutic activities, sees a 2.45% decrease from its 2020 level of $40.42 to $39.43 in 2021.

In a few instances, the new payment levels could even result in slight increases, particularly for PTs conducting an evaluation or reevaluation. For example, in 2020, use of evaluation CPT codes 97161-97163 resulted in a payment of $87.70; that payment increases to $101.89 in 2021. Similarly, payment for reevaluation CPT code 97164 will also increase this year, from $60.30 in 2020 to $69.79. (Note: actual amounts vary by locality).

Increases to the office/outpatient evaluation and management visit codes billed by primary care and some specialty physicians were at the heart of payment cuts to some three dozen professions that CMS says it was forced to implement to maintain budget neutrality. The CMS plan sparked an intensive advocacy effort at both the agency level and on Capitol hill, including historic levels of participation from APTA members and supporters fighting the cuts.

Cuts Still “Unsustainable”

While the new conversion factor is good news for PTs, the damage inflicted by CMS remains — and must be addressed, according to Kara Gainer, APTA’s director of regulatory affairs.

“The updated conversion factor and COVID relief provisions helped us partially dig out of the hole we were put in by CMS, but even with those wins, we’re still facing cuts that are simply unsustainable and damaging to patient access to needed care,” Gainer said. “We need not only to continue to advocate for more relief, but also to engage in a serious dialogue about whether the current physician fee schedule system is an antiquated response to the current demands of our health care environment.”

The new conversion factor will be integrated into the 2021 version of APTA’s Fee Schedule Calculator. Those changes should be loaded into the system in the coming weeks. APTA will share news of the updated calculator when it’s available.

Because of your work, Congress reduced the cut from 9% to an estimated 3.6%.  The fight continues and we are immensely grateful for the over 120,000 emails to Congress, taking every opportunity to raise your voice with legislators, and sending over 25,000 comments to CMS.  This campaign has been enormous and we are appreciative of your time and efforts.

View a full statement from APTA president Sharon Dunn

After an on-again, off-again approach to rules affecting the billing of code pairs that represent common, appropriate physical therapy practice, the U.S. Centers for Medicare & Medicaid Services has announced it will accept many of the pairs it had barred for use, or required to be accompanied a modifier if they were used on the same day. The changes, pressed for by APTA, are expected to reduce use of code modifiers that were creating confusion and sparking claim denials.

The good news arrives by way of the Jan. 1, 2021, edition of the National Correct Coding Initiative’s procedure-to-procedure edit tables, a listing of which CPT codes are prohibited from being billed together unless paired with the 59 or X modifier — or simply can’t be paired at all, meaning that if both services are performed on the same day only the first is paid for. In the new edit set that will take effect on Jan. 1, many of these problematic code pairs have been resolved. The retroactive change applies to both office and facility-based settings.

APTA led successful efforts to lift the restrictions, arguing that the edits not only ran counter to best practice, but were forcing overutilization of the 59 and X modifiers. That overuse led some commercial payers to adopt problematic policies that slowed and sometimes even denied claims that were submitted with the required modifier.

This latest development caps off a year that gave many PTs the equivalent of coding whiplash: The original 2020 version of the edits list included prohibitions on several code pairings commonly used in physical therapy; CMS responded to advocacy by APTA and its members and reversed that decision in early February. Then, in April, CMS responded to additional APTA advocacy and lifted more edits, only to reinstate them on Oct. 1. The latest announcement paves the way for a more settled coding environment in 2021.

The code pairing restrictions deleted in both office and facility-based settings include:

97110 with 97164
97112 with 97164
97113 with 97164
97116 with 97164
97140 with 97164
97150 with 97164
97530 with 97116
97530 with 97164
99281-99285 with 97161-97168
97161-97163 with 97140
97127 with 97164
97140 with 97530
97530 with 97113

In its announcement, CMS says that some of the positive changes are retroactive to Oct. 1, 2020, with others retroactive to Dec. 31, 2019. APTA has reached out to CMS and its NCCI contractor to get more answers on the deletion dates and provisions that could allow reprocessing of previously denied claims. The association also will update the code pairing chart available on its Medicare National Correct Coding Initiative webpage.

Read More

APTA-MS held a CE event in the Northern District on Thursday, November 20th at Holmes Community College. 17 PT professionals attended. Thank you to all that worked to put on this great event!

A bipartisan effort to avoid proposed cuts to Medicare payments in 2021 has been launched: On Oct. 30, Reps. Ami Bera, MD, D-Calif., and Larry Bucshon, MD, R-Ind., introduced legislation in the U.S. House of Representatives that would add funding to Medicare and direct CMS to essentially reset payment to 2020 levels for the 37 professions on the chopping block for cuts. Those professions include physical therapy, which was targeted for reductions that amount to a 9% decrease in payment levels.

Contact Congress to stop the cuts. APTA members and their communities have sent more than 50,000 letters to congress and more than 25,000 letters to Medicare voicing opposition to the proposed cuts. Let’s keep up the pressure: Contact your members of Congress today and urge them to take action to stop the CMS proposal to make deep cuts to Medicare beginning Jan. 1, 2021. Taking action now and in the days ahead is vital to our profession and patients. Click here to learn more.

Background

The Families First Coronavirus Response Act (FFCRA or Act) requires certain employers (generally those who employ fewer than 500 employees) to provide employees with paid sick leave or expanded family and medical leave for specified reasons related to COVID-19. The Department of Labor’s (Department) Wage and Hour Division (WHD) administers and enforces the new law’s paid leave requirements. These provisions apply from the effective date through December 31, 2020. Under the FFCRA, health care providers and emergency responders may be excluded by their employer from emergency paid sick leave and/or expanded family and medical leave.The Department of Labor issued its initial temporary rule implementing provisions under the FFCRA on April 1, 2020. In implementing these provisions, the DOL adopted a broad definition of health care provider. See APTA’s April 3, 2020 story. On August 3, a New York federal court judge invalidated several pieces of U.S. Department of Labor guidance on limitations of the Families First Coronavirus Response Act. The DOL guidance provided avenues for employers to deny paid time off mandated in the act to certain employees and in certain circumstances — one such exemption being an employee’s status as a “health care provider.” In the ruling, the judge declared the provisions invalid, declaring that the DOL guidance exceeded its scope of authority. The act’s paid time off and family leave provisions apply to employers with fewer than 500 employees On September 11, the U.S. Department of Labor’s Wage and Hour Division posted revisions to regulations that implemented the paid sick leave and expanded family and medical leave provisions of the Families First Coronavirus Response Act. The revisions made by the new rule clarify workers’ rights and employers’ responsibilities under the FFCRA’s paid leave provisions, in light of the U.S. District Court for the Southern District of New York’s August 3, 2020 decision that found portions of the regulations invalid.To summarize, the revisions do the following:

• Reaffirm and provide additional explanation for the requirement that employees may take FFCRA leave only if work would otherwise be available to them.
• Reaffirm and provide additional explanation for the requirement that an employee must have employer approval to take FFCRA leave intermittently.
• Revise the definition of “health care provider” to include only employees who meet the definition of that term under the Family and Medical Leave Act regulations or who are employed to provide diagnostic services, preventative services, treatment services, or other services that are integrated with and necessary to the provision of patient care which, if not provided, would adversely impact patient care.
• Clarify that employees must provide required documentation supporting their need for FFCRA leave to their employers as soon as practicable.
• Correct an inconsistency regarding when employees may be required to provide notice of a need to take expanded family and medical leave to their employers.

The revisions to that temporary rule will become effective immediately upon publication in the Federal Register. 

What this means:

As noted above, DOL has amended the definition of health care provider for purposes of the Families First Coronavirus Response Act emergency paid sick leave and expanded family and medical leave provisions; DOL adopted a revised definition of health care provider for purposes of the employer’s optional exclusion of employees who are health care providers from FFCRA leave. DOL’s revised “health care provider” definition is clear that employees it covers must themselves must be capable of providing, and employed to provide diagnostic, preventative, or treatment services or services that are integrated with and necessary to diagnostic, preventive, or treatment services and, if not provided, would adversely impact patient care. PTs and PTAs were considered health care providers under the previous DOL regulations on FFCRA (issued April 1, 2020). Under the newly revised DOL regulation, PTs and PTAs employed to provide health care services fall under the definition of health care provider whose employers may elect to exclude from taking expanded paid leave or emergency sick leave under the FFCRA. Note: The revised definition of health care provider as described above applies only for the purpose of determining whether an employer may elect to exclude an Employee from taking leave under the FFCRA [Emergency Paid Sick Leave Act and/or the Emergency Family and Medical Leave Expansion Act]. This definition does not otherwise apply for the purposes of the FMLA. Nor does it identify health care providers whose advice to self-quarantine may constitute a qualified reason for paid sick leave under FFCRA section 5102(a)(2).

Questions can be sent to advocacy@apta.org

Order your special APTA-Mississippi 2020 t-shirt today! This shirt was offered through the 2020 conference registration, but this special order is still available for a limited time! 

Click here to order online!

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APTA recently discussed the position of the IRS related to the CARES Act Provider Relief Funds. APTA stated that these funds are considered taxable income. The following is from the HHS provider relief FAQs that were just posted on July 13, 2020.

May a health care provider that receives a payment from the Provider Relief Fund exclude this payment from gross income as a qualified disaster relief payment under section 139 of the Internal Revenue Code (Code)? (Added 7/10/2020)

No. A payment to a business, even if the business is a sole proprietorship, does not qualify as a qualified disaster relief payment under section 139. The payment from the Provider Relief Fund is includible in gross income under section 61 of the Code. For more information, visit the Internal Revenue Services’ website at https://www.irs.gov/newsroom/frequently-asked-questions-about-taxation-of-provider-relief-payments

Is a tax-exempt health care provider subject to tax on a payment it receives from the Provider Relief Fund? (Added 7/10/2020)

Generally, no. A health care provider that is described in section 501(c) of the Code generally is exempt from federal income taxation under section 501(a). Nonetheless, a payment received by a tax-exempt health care provider from the Provider Relief Fund may be subject to tax under section 511 if the payment reimburses the provider for expenses or lost revenue attributable to an unrelated trade or business as defined in section 513. For more information, visit the Internal Revenue Services’ website at https://www.irs.gov/newsroom/frequently-asked-questions-about-taxation-of-provider-relief-payments

Provider relief fund FAQs: https://www.hhs.gov/sites/default/files/provider-relief-fund-general-distribution-faqs.pdf

Please note: HHS continues to update the Provider Relief Fund FAQs. Please review them on a regular basis. 

Questions?  Please reach out at advocacy@apta.org 

CMS has announced that outpatient therapy furnished via telehealth can be reported on institutional claim during COVID-19 PHE in its updated coronavirus waiver FAQs.

CMS has updated it’s coronavirus waivers FAQs to add a new section on outpatient therapy and telehealth. Please find below the 3 new FAQs:

1. Question: Can outpatient therapy services that are furnished via telehealth and separately paid under Part B be reported on an institutional claim (e.g., UB-04) during the COVID-19 PHE? 

Answer: Yes, outpatient therapy services that are furnished via telehealth, and are separately paid and not included as part of a bundled institutional payment, can be reported on institutional claims with the “-95” modifier applied to the service line. 

This includes:

• Hospital – 12X or 13X (for hospital outpatient therapy services);
• Skilled Nursing Facility (SNF) – 22X or 23X (SNFs may, in some circumstances, furnish Part B physical therapy (PT)/occupational therapy (OT)/speech-language pathology (SLP) services to their own long-term residents);
• Critical Access Hospital (CAH) – 85X (CAHs may separately provide and bill for PT, OT, and SLP services on 85X bill type); 
• Comprehensive Outpatient Rehabilitation Facility (CORF) – 75X (CORFs provide ambulatory outpatient PT, OT, SLP services);
• Outpatient Rehabilitation Facility (ORF) – 74X (ORFs, also known as rehabilitation agencies, provide ambulatory outpatient PT & SLP as well as OT services); and
• Home Health Agency (HHA) – 34X (agencies may separately provide and bill for outpatient PT/OT/SLP services to persons in their homes only if such patients are not under a home health plan of care).

New: 5/27/20

1. Question: Can therapy services furnished using telecommunications technology be paid separately in a Medicare Part A skilled nursing facility (SNF) stay? 

Answer: Provision of therapy services using telecommunications technology (consistent with applicable state scope of practice laws) does not change rules regarding SNF consolidated billing or bundling. For example, Medicare payment for therapy services is bundled into the SNF Prospective Payment System (PPS) rate during a SNF covered Part A stay, regardless of whether or not they are furnished using telecommunications technology. Therapy services furnished to a SNF resident, whether in person or as telehealth services, during a non-covered SNF stay (Part A benefits exhausted, SNF level of care requirement not met, etc.) must be billed to Part B by the SNF itself using bill type 22X, regardless of whether or not they are furnished using telecommunications technology.

New: 5/27/20

1. Question: Can outpatient therapy services be furnished and paid separately for patients receiving Medicare home health services? 

Answer: No. For patients under a home health plan of care, payment for therapy services (unless provided by physicians/non-physician practitioners) is included or bundled into Medicare’s payment to the HHA, and those services must be billed by the HHA under the HHA consolidated billing rules. Patients should first be assessed for whether they are eligible to receive therapy services under the home health benefit prior to initiating outpatient therapy services. Receiving therapy services under the home health benefit may be in the best interest of the patient as there is no applicable coinsurance, copay, or deductible for such services (with the exception of negative pressure wound therapy using a disposable device), and the patient may also have a need for skilled nursing services, home health aide services, or medical social services under the home health benefit. However, if the patient is not eligible for home health care, including when it is not possible to provide in-person therapy services in the patient’s home (i.e., the patient is not under a home health plan of care), then outpatient therapy furnished via telehealth under Part B could be an appropriate alternative and separately billed, assuming all applicable requirements are otherwise met.

New: 5/27/20

Begins on page 70: https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf

Questions?  Reach out at advocacy@apta.org 

The American Physical Therapy Association (APTA) recently released guidance detailing known and anticipated actions as a result of the CARES Act, recently passed into law by Congress and President Trump. In addition to the $2 trillion stimulous package, the Act also created many new policies and flexibilities for PTs and PTAs.

Click here to view full details.