The following transcript was created using artificial intelligence and may contain typos, omissions, or other errors.

Leah: Hello and welcome to this APTA podcast. I'm Leah Fogarty, part of the Member Communications team here at APTA. It's summer, a time for some of our favorite rituals and traditions. Breaking out the grill, hopefully finding some time to spend with family and friends outdoors. And of course, we're waiting for the Centers for Medicare and Medicaid Services to release the proposed Medicare Physician Fee Schedule.

For another year, the budget-neutral payment system has led to proposed payment cuts threatening all clinical specialties paid under the fee schedule. But there is cause for celebration in the form of two big wins for the profession relating to PTA supervision and plan of care requirements. At more than 2200 pages, the 2025 proposed rule is not exactly a beach tread, but thankfully I'm joined by two APTA staff experts who have sorted through the rule and its implications for the physical therapy profession.

Andrew Amari and Rachel Miller are health policy and payment specialists within APTA's public affairs unit. They're going to tell us some of the highlights from the proposed rule, but don't forget on our website we have other resources that go into more of the details. We've got a two-part article on the APTA website on the fee schedule, will link them in the show notes or you can find them using the search feature. Andrew and Rachel will also be hosting the APTA regulatory, legislative and payment update on August 8th at 2:30 PM Eastern Time, which will cover the details of both the 2025 Medicare Physician Fee Schedule and the 2025 Home health proposed rule. The webinar is free for APTA members, and it gives you a chance to ask these experts some questions and it will be recorded if you can't make it. So let's start this episode with one of the big headlines from the fee schedule: Proposed cuts to the conversion factor. Andrew and Rachel, these weren't unexpected, but they aren't what we wanted to see. Tell us what CMS proposes and this fee schedule, and explain why we shouldn't be surprised to be in this situation.

Andrew: Well, first, thanks so much for having us, Leah. We really appreciate the opportunity to come on and talk about the rule, which obviously impacts the vast majority of our member physical therapists and, like you mentioned, it wasn't unexpected, but this year we did receive another cut. CMS is proposing a 2.8% reduction to the conversion factor relative to the 2024 conversion factor for all Medicare Part B providers. Of course, that includes our member physical therapists.

You know. What does this mean? Very, very directly, this is a decrease in total reimbursement for many commonly used CPT codes. Actually, the conversion factor is applied to all CPT codes that are submitted for reimbursement. But, as you sort of alluded to Leah, you know we were expecting around a 3% cut. This is something that we've been dealing with for the last three years now in a row. And you know, if you look back over a decade, it really is almost the vast majority of years we've seen cuts in the years that we didn't see cuts, there were very, very marginally increases and so it's more of the same this year. But part of that is because what our members should know about is that CMS is legislatively mandated to keep the system budget neutral, so and that means that the total expenses in the system are not permitted to increase by more than $20 million each year.
And if they do exceed that $20 million mark, CMS has to offset those costs and typically they do it by cutting the conversion factor since it's applied uniformly across all clinical specialties that are paid under the fee schedule. Of course, that means that our providers are the ones who bear the brunt of these changes. But it's not felt alone. It is felt by all of the clinical specialties.
Fortunately, in this year's fee schedule, CMS is asking our stakeholders to comment on ways that the agency can account for expenses of running practices through inflationary adjustments to the practice expense component of our codes. And one of the three crucial pieces, you know that make up the CPT pricing is that PE expense and so you know one of the pieces of good news is that we did for 16 of 19 codes that we submitted to CMS for an update in the practice expense, we actually got updates and increases to the vast majority of them. And so that's sixteen of those 19.
And what that means is that even though we're seeing a -2.8% cut to the conversion factor, the PT impact is slightly lower than that average cut. So we have a -2.5% overall cut for our services across the board.

So with that being said, it's a bad proposal on the year. Unfortunately, it's not within CMS's power to modify this, so we are going to be working on this through the legislative side and as we have in the last few years. But in addition to just working on the more immediate fix to the cut, we are hoping for additional inflationary updates in the future for a broader fix to the fee schedule.

Leah: So we've seen a pattern in recent years of Congress intervening at the last minute to mitigate the impact of the cuts. Do you think that this could be in store again with the 2025 fee schedule and if so, what is APTA doing to get us out of this cycle of cuts and congressional intervention?

Andrew: I do. That's a great question, Leah, and you know to better frame the conversation, in 2024, we saw CMS release a rule that called for a 3.4% reduction to the conversion factor. Of course, that cut went into place in January, and the advocacy by APTA and other provider organizations to Congress ultimately resulted in a lower cut. It ended up being a 1.69% reduction after the congressional intervention. And so our hope is that we can avoid that similar situation. Our lobbyists and our government affairs unit are already working diligently with not just, you know, not just the therapy organizations, but also all of the clinician stakeholder groups, and this includes the big ones such as the American Medical Association and we're all working to mitigate the impact of these cuts, talking about how these cuts are not unique to us, they are across the entire system. We are all motivated to work on them together to get something in the immediate changed. So in this year's rule, and also we're hoping that this is a group that we can work with on broader reform to the fee schedule as well.
And there are, you know, there is power in numbers. So when CMS and Congress see that all the providers are up in arms about how significant these cuts are and how brutal and ongoing they've been, hopefully they are more likely to act on it, just as we saw back in March for the last year's fee schedule. And you know, just as I've alluded to a few times, we do hopefully want to get rid of this cycle. We don't wanna have to keep having these legislative fixes each year and our folks are lobbying for a bill in Congress that would enact a permanent annual payment update tied to the Medicare Economic Index. And that's probably not a popular term among our average listener, but the MEI is a yearly measure of inflation for physicians’ and other clinicians’ practice costs and general wage levels. And so the bill that I'm referencing is called the strengthening Medicare for patients and Providers Act or HR 2474. And this bill is really important because while the MEI and that's again the Medicare Economic Index continues to increase with a projection of 3.6% in 2025 alone, provider payments of course remain stagnant because of budget neutrality and even get lowered. And so this makes it impossible for providers who take Medicare patients to stay afloat. But having an inflationary update built into the system would do a lot in preserving payments, if not increasing them from a year-to-year basis. But in all APTA has really changed its approach to Advocacy on Medicare payments. We're not just fighting the cut every year. We want to reform the fee schedule. We want to fix the fee schedule, so to speak, and we do recognize how unsustainable the current system is for our membership. I think we know it. We're more intimately familiar with it than any other group at APTA, and we are dedicated to fixing it and more importantly, like I mentioned before, this is a universal sentiment among clinicians paid under the fee schedule. We're not alone in this fight. We are working with the broadest group of clinician stakeholders.

Leah: Well, thanks for that, Andrew. Let's move on to some good news. Despite the cuts, there are also several significant policy wins for the profession, which is in no small part driven by APTA’s regulatory and legislative advocacy efforts. So let's start by talking about PTA supervision.

Rachel: Great. I’d love to take this question as this proposal is a huge opportunity we have this year to secure a win for the profession after really years of persistent advocacy. So to provide some background on the issue, as it stands, all settings under Medicare except private practice allow for general supervision. In other words, if you're a PTA providing care to a Medicare patient in a private practice setting, the physical therapist who was overseeing you must be readily available in the building to provide supervision as is necessary. So APTA has advocated for many years to change this policy and make supervision levels consistent across all settings under Medicare.

Ultimately, this would allow the PTA to practice at the top of their licensure and free up the PT to do other things like administrative tasks or see more patients as general supervision only requires that the PT be immediately accessible, but not necessarily physically present with the PTA when they're providing care. So to be clear what CMS is proposing this year is that private practice PTs who are enrolled as Medicare providers would be allowed to bill for and receive Medicare Part B payment for therapy services that are furnished under general supervision. In this change, CMS specifically pointed to APTA arguments that were submitted through the comment tool that we utilized last year on the 2024 fee schedule and that was in response to the request for information on PTA supervision. So we knew that last year CMS was interested in changing the requirement and so they asked for comments from different members who are utilizing PTAs to get more information on whether or not it was feasible in this setting. So CMS did specifically reference APTA’s member submissions provided evidence proving that under direct supervision, patients have more limited access to therapy services and they would under general supervision.

The agency also went on to describe how a change to general supervision has the potential to allow PTAs the flexibility to better accommodate patients’ availability and ensure that patients are receiving necessary therapy services. So really this is a direct result of our advocacy at work.

Leah: Well, that's great, Rachel. Thank you. Our legislative team has also been advocating for this change. The APTA-backed EMPOWER act is nearly identical to this proposed change, and it has bipartisan support in Congress. APTA has also been advocating for reducing administrative burden for PTs. What is the proposed rule say in terms of plan of care requirements?

Rachel: You're totally right. So both APTA's legislative and regulatory teams have been working really hard to advance the profession, and this is for both PTA supervision change that I just mentioned and the plan of care proposal, they’re really evidence to the advocacy work that we're doing. So in the plan of care proposal this year, CMS is proposing to allow the physician’s signed order or referral to demonstrate the initial certification of the PT’s plan of care. So again, under current rules, PTs must send their plan of care to the referring physician and security signature within 30 days. But in this the PT is bearing all the responsibility of getting that signature. Otherwise, the PT has to choose between stopping treatment of the patient or proceeding with treatment, but at the risk of not being paid by Medicare. So obviously this has been a huge point of contention for all of our members because not only does it increase the administrative tasks that's on their plate, but it also forces them to delay patient care if you're unwilling to run the risk of not being paid for the services that you're providing to the patient.

Now there are a couple things to note on that come along with this proposal. So first the signed and dated referral or order must be supported by documentation. Now CMS is describing this documentation as the referral being located within the patient’s medical record and they're being evident that the PT sent the plan of care to the referring physician within 30 days of the completed initial evaluation. So those two requirements must be met in order for this new proposal to be used by our members. Additionally, CMS is also soliciting comments on whether there should be a deadline for making changes to the plan of care when there currently aren't any deadlines right now. As well, they are also seeking comments on whether there should be a time limit on the order or referral when it's intended to serve as the initial certification. Specifically, the agency is asking whether 90 days or even a different timeframe is appropriate in this situation. So obviously APTA’s regulatory team is gonna be using our comment letter to respond to these requests and ultimately we're going to support the decision making of the treating physical therapist in these situations.

Leah: This is another area that our legislative team has been working on too, right.

The Reduce Act, which is an APTA backed, complementary pending legislation that was the basis for these proposed changes, recommends that referral sources have 10 business days to modify the plan of care.

The proposed rule also has some small changes relating to telehealth services. What do we Members need to know about this aspect of care?

Rachel: Correct. There are a couple things that are being changed for telehealth that we want to keep members aware of. So first, as it stands, physical therapists will not have access to telehealth starting in 2025. So we knew this was coming and this is because of expirations from the end of the public health emergency and really because physical therapists are not currently on the list of telehealth practitioner practitioners. So really the only way for this to change is for some sort of congressional intervention. Right now, APTA is lobbying Congress on this issue through the expanded Telehealth Access Act. This would put PTs on the list of permanent telehealth providers, which is what we're looking to achieve. So I encourage you all to check out the APTA bill tracker for updates on the status of that bill as we continue to lobby.

This year in the fee schedule, the agency also decided that no provisional codes would move to permanent status in the fee schedule rule. So this does include the list of PT codes that we submitted to CMS earlier this year.

However, CMS has proposed to move the caregiver training codes that just became available for use this year in 2024, they're proposing to move these set of codes to the provisional list. So if PTs do make it onto the list of telehealth providers via congressional intervention, those codes would be available alongside the other set of commonly used PT codes via provisional status on the list.

CMS also proposed a change that won't impact PTs yet, but it could have potential use in the future and that is to include audio-only communication technology among the interactive telecommunications systems eligible for payment via telehealth. Now, there are some caveats here. First, the technology must be two-way and real-time, and it can be used only when the patient is incapable of or doesn't consent to using video technology. Plus, you'll also have to use a modifier when you submit for these codes. Now, if Congress does add PT to the list of approved telehealth providers, PTs could take advantage of this new allowance in 2025. However, because most physical therapy codes do require the PT to have that visual contact with the patient, the use of audio-only telecommunication may be limited.

Now the last change that I want to note is that CMS has decided via the hospital outpatient prospective payment system rule to Align rulemaking on telehealth services in both settings – in hospital outpatient and via the fee schedule in Part B.

So this comes after confusion that the agency caused at the end of the public health emergency, when CMS ultimately tried to limit the provision of telehealth services by institutional providers. Now, if you remember, APTA did a lot of advocacy on this issue and we were able to kind of set the record straight there. But with this new alignment, our understanding is that CMS is trying to make it clear when Congress makes any changes to the list of telehealth providers that those are changes will apply to both hospital outpatient and Medicare Part B the fee schedule.

Fogarty, Leah: OK, great. Oh, that's good information. Another key area that we wanted to talk about is the Medicare quality payment program, which includes the Merit-based Incentive Payment System. What do our members need to know about the proposed changes to QPP and MIPS?

Andrew: So you know Leah, this is a this is an area that I think is a little less exciting compared to what the what Rachel was just talking about the issues with plan of care certification and with PTA supervision. MIPS in the last few years has been pretty exciting and there have been major changes within the program. Last year, we had CMS introduced the first MIPS Value Pathway for PTs to use, and that was the musculoskeletal rehabilitation MIPS value pathways, or MVP, as they're calling it. And also we saw a less exciting change last year where PTs would finally be subject to the promoting interoperability reporting under traditional MIPS. Of course, this year there's really not as many significant changes. There are a few things that we’ll point out, but we're really focused on some of the larger trends moving forward. Still, participation in both traditional MIPS and the MVPs don't have significant incentive.

The highest payment incentive you can earn under the program is still under 3% and for PTs, because of the limited participation options, oftentimes it can be even lower.

Additionally, CMS is looking to shift to the MIPS value pathways from traditional MIPS almost entirely by 2029. We continue to believe that this is not realistic in the limited options, and while the MVP is a great start, it's only one option and not every PT will be able to use that because the cost measure, which there's only one for PTs is on low back pain. And so if you don't treat patients for low back pain, then it ends up being a pretty limited opportunity for PTs.

And so, you know, moving forward, we definitely see some issues with larger scale reform for quality and the role that PTs and other nonphysician providers have in the system compared to their physician counterparts.

But you know, talking a bit about those broader trends, I do wanna talk also just briefly about some of the specific updates that were proposed in this year's rule. So probably most importantly, you know there were no changes to the PT-OT measurement measure set, so you know it's a bit of a, you know, disappointing that we didn't get any additional measures but also good that they're not removing some because they have done that in the past. But we also did see some new measures that were added to the Musculoskeletal Care MVP. And so those are MSK 6 through 9 and that's patients suffering from a neck or upper extremity or back or lower extremity injury who improve in pain. And then they also added a urinary incontinence measure, that's Q050, and also added a new improvement activity.

But this is really just a uniform improvement activity that they're adding to all MVPS, and that is on vaccination status for practice staff. Otherwise no other major changes to the MVP, but it is good just to see a few new measures get added on there. We will continue to submit additional measures through the MVP maintenance process that happens outside of fee schedule rulemaking. It's one of the unique areas of the fee schedule that it sort of happens outside of the ordinary notice and comment rulemaking process.

But outside of the MVP, we'll just note that there was no changes, CMS didn't make any changes since last year on the promoting interoperability requirements. PTs are still going to be required to report on them, however I think it's just good to mention that there are still exemptions or exceptions that PTs can qualify for if they don't have the ability to control the selection of CEHRT, they can qualify for an exception. It's very simple. Basically, you go on to the CMS quality payment program website and you can basically check a box to indicate that you don't have and you meet the exception for a CEHRT exception and you can get that you'll hear them, excuse me, you'll hear an answer from them within one to two days at most, and you'll have that part of promoting interoperability reweighted for MIPS. And for those of you, you know I've been saying CEHRT. CEHRT is the certified electronic health record technology and that's what's required to meet the promoting interoperability portion of MIPS participation. And you know, this is a big this is a big issue with PTs because we have less access to certified EHR technology compared to our physician peers. And so another area that we wanted to talk about is that CMS is now going to propose for an exception for reweighting that would allow clinicians who essentially weren't able to submit complete quality data due to a third party intermediary being the one that they were supposed to submit it on the clinicians’ behalf and they didn't, essentially, there would be an exemption that would allow you to reweigh any of the three categories. So that's quality, improvement activities, or promoting interoperability. So those are the three major performance categories. If that wasn't reported due to your third-party intermediary, then you would have an exemption under the new reweighting proposal. But really, that's about it for the quality payment program this year, there's still stuff happening, but it's definitely a little quieter than in recent years.

Leah: Well, OK. So we've covered both the highs and the lows of the 2025 proposed fee schedule, but it's important to remember that this is just the proposed rule, right and CMS is looking for feedback. So what will APTA be doing and how are we helping members share their experiences with CMS?

Andrew: This is definitely this is Rachel and I. This is our job. You know, we're working on drafting come a comment letter that comprehensively covers all of the proposals that affect physical therapy. You know we will be creating policy arguments, we will be backing everything we talk about with evidence and data towards our positions, and, of course, we're gonna be collaborating with our sister therapy organizations in the American Occupational Therapy Association and our friends over with the speech-language pathologists at ASHA [the American Speech-Language-Hearing Association]. And we approach this on both the regulatory and legislative sides. You know, we were talking earlier about working with our Government affairs group to get legislative change on the cuts? We're also gonna be advocating to members, you know, we're doing the podcast just like this one.

We have email blasts, social media, we're going to have our webinar that Leah you mentioned earlier in this podcast episode. And so I think those are sort of the core issues, but ultimately we have long thought how important it is to engage our membership in complementary advocacy on these issues because at the end of the day, we have 100,000 plus members that have unique perspectives and these issues affect them all independently and uniquely.

And so what we've been doing in the last few years is providing a couple of different ways for our members to get involved. The one that I think people are most familiar with are template comment letters and so you just put your email in and it submits a comment letter that says the same thing on your behalf and it's a great option if you don't have a lot of time. But we have been trying to move towards some more individualized feedback from our membership and the reason why this is so important is because CMS is not the same as our legislative side of advocacy because they are not moved by the sheer number of submissions that they get. They are looking for compelling stories for quality policy arguments, and so we have developed a few years ago our regulatory comment tool. What it does is it guides you through the primary issues that we wanna talk about. And so for this year, it's really going to be the cuts. It's going to be the plan of care certification signature exemption. It's going to be the PTA supervision to move those across the finish line.

And so, you know, this is a Microsoft form. It takes usually for new, for new members who have never submitted a comment through this before around 30 minutes.

But for folks who have used it before, around 15 minutes and it basically guides you through the submission process and the idea is that we wanted to show the breadth and you know, the different areas from which members feel the exact same way as we do. And it is something that we've seen in action like Rachel mentioned earlier, the RFI that CMS put forth on the PTA supervision last year, they were directly quoting some of the submissions that were through the comment tool last year and it was really great to see that advocacy and action.

But you know, members have until the September 9th deadline and that's September 9th at 5:00 PM Eastern Time. They do cut off that submission time at that 5:00 PM Mark. And so, you know it's a great opportunity. It's a great way to get involved in advocacy, and it's a great way to talk about the way that these policies stand to help you in your practice. And really, you know, if you have any questions, you can always reach out to advocacy@apta.org and we're happy to guide you through it.

Leah: Thanks, Andrew. And speaking of that comment tool, the APTA regulatory comment tool as it's called it just one a 2024 power of association Silver award from ASAE, which is the American Society of Association executives. And these awards recognize associations that have gone above and beyond their mission. So congrats to you both for that really big feather in your cap. And also want to say Andrew and Rachel, thank you so much for your insights and all of the work you are doing related to the proposed rule. And as a reminder, that webinar that we've mentioned on August 8th, the APTA regulatory, legislative, and payment update that will be coming at 2:30 PM on August 8th.

As always, APTA will keep you informed as we ramp up our advocacy efforts related to the fee schedule. Keep an eye out for our email newsletters and check our social media to learn how you can help us fight to fix the fee schedule. Thanks for listening and we'll let you get back to your regularly scheduled summer fun.