New guidance issued by CMS now allows PTs in private practice to make full use of telehealth with their patients under Medicare Part B. Previously, only limited e-visits and other “communication technology-based services” were allowed; the change now includes PTs among the health care providers permitted to bill for real-time face-to-face services using telehealth. This policy change follows a robust advocacy campaign by APTA members and staff.

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To increase the availability of needed health care services during the COVID-19 PHE, in response to suggestions by stakeholders, CMS will allow PTAs and OTAs to perform maintenance therapy services under Medicare Part B for the duration of the public health emergency.

CMS states it will permit the PT or OT who established the maintenance program to delegate the performance of maintenance therapy services to a PTA or OTA when clinically appropriate.

Acknowledging that the COVID-19 pandemic should be the focus of attention, CMS released a proposed rule that makes no changes to quality reporting.
CMS fact sheet

The big picture: A 2.9% increase and continued efforts to lessen administrative burden.
In light of rapid changes being made to Medicare in response to the COVID-19 pandemic, the U.S. Centers for Medicare & Medicaid Services issued a pared-down proposed rule for inpatient rehabilitation facilities that sticks to the basics — including a 2.9% payment increase and the elimination of physician evaluations within the first 24 hours of patient admission. The 2.9% increase represents an estimated increase of about $270 million in payments to IRFs. 

In a fact sheet on the proposed rule, CMS writes that it’s meeting a statutory obligation to update Medicare payment policies annually, but the COVID-19 pandemic demands widespread attention and “CMS has limited annual IRF rulemaking required by statute to essential policies.” 

The final rule would go into effect on October 1, 2020. APTA will provide comments on the proposed rule before the June 15, 2020, deadline.

Also notable in the proposed rule:

• No changes to quality reporting. For the first time in years, CMS will leave IRF quality reporting measures untouched from what was set in place in the previous year.
• Changes to the geographic wage index, and a limit on decreases. The proposed rule adopts geographic delineations proposed by the Office of Management and Budget to determine whether a provider is considered a rural or urban facility — a key element in determining the IRF wage index. CMS hopes to accompany that change with a 5% limit in FY 2021 in any decrease in a facility’s wage index compared with its wage index for the prior fiscal year to help providers adapt to the revised OMB delineations. 
• Non-physician providers allowed to perform coverage service and documentation. CMS is proposing that non-physician practitioners — typically defined by the agency as physician assistants, nurse practitioners, and clinical nurse specialists — be permitted to perform duties currently reserved for physicians, as long as those duties are within the practitioner’s scope of practice established in state law. 
• Flexibility around physician evaluations. Although the proposed rule would lift the requirement for a physician evaluation within the first 24 hours of admission, IRFs would still have the ability to conduct a visit in that timeframe if conditions warrant. 
• Another call for comments on reducing administrative burden. CMS accompanies almost every proposed rule with an invitation for comment on changes that could be made to reduce unnecessary paperwork and other administrative burdens — an invitation that APTA takes up at every opportunity.

Don’t forget to use the CQ modifier if more than 10% of a service is furnished by a PTA.

TRICARE, the health insurance system used throughout the military, announced that it has officially revised its policy manual to recognize PTAs (and occupational therapy assistants) as authorized providers, outlining the rules and requirements governing assistant qualifications, scope of practice, supervision, and reimbursement. 

Now it’s up to TRICARE contractors to do the same within approximately 30 days.

As reported earlier, beginning with date of service on April 16, PTAs are recognized as authorized providers under TRICARE and thus eligible for reimbursement for covered services rendered to TRICARE beneficiaries.

Take note: The CQ modifier must be appended to the claim when more than 10% of an outpatient physical therapy service is furnished by the PTA. Check out APTA’s Quick Guide to Using the PTA Modifier.

The presence of the modifier shouldn’t impact claims processing. However, if claims are denied, they may need to be resubmitted if the claims are sent to contractors before they fully implement the change. 

Advocacy efforts by APTA and its members helped CMS and its coding contractor reverse earlier changes that complicated (and sometimes thwarted) a PT’s ability to provide efficient, effective care.

What Happened

Prior to the latest change, reimbursement would be denied if, for example, code 97530 (therapeutic activities) was paired with 97116 (therapeutic procedure) without use of the 59 or applicable X modifier. Those code pairings have been eliminated. Now PTs working in private practice and institutional settings can pair many codes without adding the 59 or applicable X modifier. For a complete list of edit changes go to APTA’s National Correct Coding Initiative webpage .

Which Payers These NCCI Edit Changes Apply to

Medicare and Medicaid programs follow CMS’ NCCI procedure-to-procedure edits. Additionally, most insurers also follow the NCCI PTP edits. APTA encourages providers to use the information in this article and found on the CMS PTP Coding Edits webpage to communicate with commercial payers regarding these edit changes.

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