A major win, and a major challenge: that's what APTA and the physical therapy profession are facing now that the US Centers for Medicare and Medicaid Services (CMS) has released the final 2020 Medicare physician fee schedule. While the agency seems to have listened to critics and made significant positive changes to the way it will calculate payment when therapy services are delivered "in part" by a physical therapist assistant (PTA), it inexplicably ignored thousands of comments, including a letter from members of Congress, calling for reconsideration of a proposed 8% cut for physical therapy payment and host of other disciplines in 2021. The planned cuts set the stage for intense advocacy efforts by APTA and other professional organizations representing a wide range of health professions including psychologists, occupational therapists, ophthalmologists, chiropractors, and clinical social workers. [CMS has also issued a fact sheet and press release on the final rule.]

The win: CMS backed off from an ill-advised system to calculate when therapy services delivered "in part" by a PTA would trigger 15% lower Medicare Part B payments beginning in 2022.

Background: It wasn't CMS' idea to create a code modifier (CQ or CO) to denote services delivered "in part" by a PTA or occupational therapy assistant (OTA)—that was something introduced by federal law—but the way CMS proposed to roll out the system lacked understanding for the real world of physical therapy care delivery. In addition to the proposal being misinformed, it was overly burdensome, and would've likely reduced patient access to needed care.

What was proposed: CMS forwarded the idea of a "de minimis" 10% standard that would trigger use of the modifier whenever a PTA or OTA provided outpatient therapy services for 10% or more of the total time spent furnishing the service. The proposal stipulated, among other things, that the modifiers be applied to the claim when services were delivered concurrently with a physical therapist (PT), and required all codes to be accompanied by a written explanation of why the modifier was or wasn't used.

What's in the final rule: APTA and its members engaged in an intensive advocacy effort around these provisions, and CMS reconsidered its approach, adopting a system that's consistent with many of the association's recommendations. Among the wins in the new rule:

• When the PT is involved for the entire duration of the service and the PTA provides skilled therapy alongside the PT, the CQ modifier isn't required.
• When the same service (code) is furnished separately by the PT and PTA, CMS will apply the de minimis standard to each 15-minute unit of codes—not on the total PT and PTA time of the service, allowing the separate reporting, on 2 different claim lines, of the number of units to which the new modifiers apply and the number of units to which the modifiers do not apply.
• The proposed documentation requirements are scrapped.

"This is a huge win for physical therapy under Medicare," said Kara Gainer, APTA director of regulatory affairs. "When we speak with a unified voice, make a clear case for our position, and offer viable options, we can make a difference with CMS. In this case, the difference our members made was huge."

The challenge: For now, CMS is sticking to its proposal to cut payment for physical therapy providers by an estimated 8% beginning in 2021.

Background: CMS thinks that values for office/outpatient evaluation and management (E/M) codes are too low—an opinion that APTA doesn't necessarily oppose.

What was proposed: The Medicare physician fee schedule is budget-neutral. To increase values for the E/M codes while maintaining budget neutrality under the fee schedule, CMS proposed cuts to other codes to make up the difference beginning in 2021. Under the plan, physical therapy could see code reductions that may result in an estimated 8% decrease in payment. Other professions stand to lose as well: for example, ophthalmology would see a 10% cut, audiology would face a 6% reduction, chiropractic care would drop by 9%, and clinical social workers would see payment decline by 6%. In total, 36 specialties are facing reimbursement reductions in 2021. However, CMS has not yet determined the actual cuts to each code.

What's in the final rule: Despite a flood of comments into CMS—more than 10,000 from APTA members alone—and a collaborative advocacy effort among professional organizations that included a letter signed by 55 members of Congress opposing the cuts and a provider sign-on letter signed by 10 associations, CMS left the proposal untouched in the final rule.

CMS briefly acknowledges the reaction it received, writing that "we understand commenters' concerns with the magnitude of the redistributive adjustment necessary." The agency explains that it was reluctant to make any changes to the plan given that "we do not know the magnitude of redistribution resulting from other policies we may adopt through rulemaking before then," and characterizes a table of proposed 2021 code valuation adjustments included in the final fee schedule as being "for illustrative purposes only."

"APTA made it very clear to CMS that the association and its members oppose the cuts proposal for 2021, and Congress reinforced APTA’s message," said Katy Neas, APTA executive vice president of public affairs. "APTA and its members, along with literally thousands of other health care providers, made compelling arguments and offered thoughtful alternatives that were seemingly completely ignored as the final rule was drafted. We are taking CMS very seriously when it says that this plan is subject to change. We've brought the association's voice to bear on the PTA modifier issue, and CMS listened. Over the next 12 months, we will leverage every possible opportunity – working with Congress and CMS --to change this flawed policy."

More from the fee schedule: MIPS continues to expand, and CMS continues to move toward a more streamlined system.

The final rule also makes changes to the Merit-based Incentive Payment System (MIPS). Starting in 2020, CMS will add measures for diabetic foot and ankle care; peripheral neuropathy: neurological evaluation and prevention evaluation of footwear; screening for clinical depression and follow-up plan; falls screening and plan of care, elder maltreatment screen and follow-up plan; preventive care and screening: tobacco use: screening and cessation intervention; dementia: cognitive assessment, functional status assessment, and education and support of caregivers for patients with dementia; falls: screening for future fall risk; and functional status change for patients with neck impairment. The rule also removes 2 measures: pain assessment and follow-up, and functional status change for patients with general orthopedic impairments.

Other changes to MIPS include the following:

• Data completeness for the 2020 performance year will be set at a 70% sample for both Medicare Part B claims-based reporting and clinician or group reporting via a registry.
• Groups will be able to attest to an improvement activity when at least 50% of the MIPS-eligible clinicians perform the activity, at a rate of at least 50% of the group's providers with a National Provider Identifier (NPI) performing the same activity for the same 90 continuous days in the performance period.
• The Promoting Interoperability category will continue to be reweighted for PTs by CMS in 2020, meaning that PTs won't be scored in this category.
• MIPS-eligible clinicians with a final score of 45 will receive a neutral payment adjustment in 2020, with the score rising to 60 points for the 2021 payment year. The exceptional performance bonus will be triggered with a score of 85 points in both 2020 and 2021.
• CMS will also continue its shift to a streamlined version of MIPS, which it has dubbed "MIPS Value Pathways," (MVPs) for 2021 and beyond.
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Also notable in the 2020 PFS: KX modifier thresholds, dry needling, biofeedback codes, negative pressure wound therapy, and more.

As always, the fee schedule rule is expansive. Here are some quick takes on other 2020 PFS provisions of interest to the physical therapy community.

The KX modifier gets a slight bump. The threshold amount for use of the KX modifier will rise from $2,040 to $2,080 for physical therapy and speech-language pathology services combined, and by the same amount for occupational therapy services. The targeted medical review threshold remains at $3,000. These changes will be incorporated into APTA's multiple procedure payment reduction (MPPR) calculator, which will be live before January 1, 2020.

Dry needling codes have been added—but CMS won't be covering them. The final rule adds 2 dry needling codes (1 for insertions in 1-2 muscles, and another for insertions in 3 or more), but the codes will remain unpaid unless a national coverage determination says otherwise. If the codes were covered, CMS believes they should be considered as "sometimes therapy" procedures rather than "always therapy."

Biofeedback codes are now available as "sometimes therapy." Codes related to biofeedback training of perineal muscles or anorectal or urethral sphincters have been added to the biofeedback family, and valued at .90 work RVU for the initial 15 minutes of treatment and .50 work RVU for each additional 15 minutes of one-on-one contact.

Negative wound pressure gets coding values. After some 3 years of work, CMS has established relative value units (RVU) and direct practice expense inputs for codes associated with negative wound pressure therapy, with a .41 work RVU for code 97607 (vacuum-assisted drainage collection for total wound surface area of 50 square centimeters or fewer) and .46 work RVU for 97608 (vacuum-assisted drainage collection for total wound surface area of 51 square centimeters or more).

CMS remains unclear when it comes to PTs' use of remote physiologic monitoring codes. Last year, CMS said qualified health care professionals can furnish and bill for these services, as long as it’s within their scope of practice. APTA interprets this to include PTs, who are included in the American Medical Association’s definition of "qualified health professionals." In response to APTA’s continued request for clarity from the agency, CMS advised that PTs with billing questions related to these codes contact their Medicare administrative contractor(s). In the final rule, CMS says it will "consider these and other questions." Once again, the issue seems to be up in the air.