You might think advocacy to the U.S. Centers of Medicare & Medicaid Services is something that happens in fits and starts — after CMS releases a proposed rule, when final versions are issued, or when CMS asks for input, for example. That's not exactly how it works.

The fact is, APTA's advocacy efforts with CMS never stops. While concerted grassroots pushes can happen after a proposed rule is released and comments are being accepted, it's crucial to stay engaged with the agency all year long. The reason is simple: existing rules, policies, guidance, and manuals can always be changed, and CMS always has plans in development.

Given the moving-target nature of CMS advocacy, it's not easy to provide a complete picture of APTA's efforts. But here's a snapshot of our CMS-related work in several important areas.

Telehealth

When CMS expanded its list of telehealth providers to include PTs and PTAs for the duration of the public health emergency, we seized the opportunity. We've been carefully monitoring usage and care and building the case to make the telehealth option permanent (something some commercial insurers have already done). Among our recent work:

• We're in ongoing communication with the Medicare Payment Advisory Commission, or MedPAC, to educate them on the use of telehealth by therapy providers. MedPAC is an influential voice with Congress and CMS, and we're helping them see the benefits of telehealth. This has included an APTA-led joint letter to correct MedPAC telehealth misperceptions, drafted on behalf of APTA, the American Occupational Therapy Association, the American Speech-Language Hearing Association, the National Association for the Support of Long-Term Care, the American Health Care Association, and the National Association of Rehabilitation Providers and Agencies.
• We've requested that CMS add physical therapy codes to the permanent Medicare telehealth services list. It was clear before the pandemic that codes associated with physical therapy should be permitted when delivered via telehealth; the pandemic and the temporary inclusion of those codes has only underscored the fact that it's past time for a change.

PTA Differential and CQ Modifier

Beginning in 2022, CMS is required to implement a differential in payment of 85% when therapy services are delivered "in whole or in part" by a PTA, and has set the threshold at 10% or more of those services. We continue to push CMS to explore whether it has any legal authority to mitigate the impact of the differential, such as by exempting rural and underserved areas. We are also pressing for more clarity about actual implementation of the rule. Recent activities:

• We met with CMS about the application of the CQ modifier and implementation of the differential policy. The CQ modifier is required to indicate that at least 10% of a service was provided by a PTA. CMS subsequently issued additional guidance on application of the CQ modifier, which we're now working with the agency to revise, as we disagree with their interpretation of their own policy. Unfortunately, CMS feels it must continue to proceed with implementation of the differential in 2022.

Physician Fee Schedule

Prompted by the advocacy of APTA members and other organizations, Congress stepped in to blunt payment cuts to some three dozen professions in 2021, knocking a planned 9% cut to codes associated with physical therapy to an estimated 3.3% cut. Our position: Even that reduction isn't sustainable and ultimately puts patients at risk. Some of our efforts:

• We met with CMS numerous times and will continue to do so. Between June and November 2020, APTA, AOTA, and ASHA met with representatives from CMS, the U.S. Department of Health and Human Services, and the federal Office of Management and Budget to propose options to mitigate the cuts and urge full consideration of their impact.
• We're already fighting in anticipation of additional cuts in 2022. There is a small window of opportunity to influence policies that might be included in the upcoming year's fee schedule rule, and we're not wasting any time. We've already sent CMS a letter with recommendations on how to mitigate additional planned cuts in the 2022 fee schedule and a separate letter on CMS' legal authority to amend supervision requirements of PTAs in private practice as well as the plan of care certification requirement. APTA also met with CMS to stress the importance of eliminating or mitigating the cuts to physical therapy payment next year and to discuss the importance of maintaining access to telehealth after the PHE ends as well as policy changes that would reduce administrative burden.

Other Engagement

Because the reach of CMS is so extensive, it's important to keep up in both big-picture and more topically focused ways. The primary tool available to organizations outside CMS is comment letters and other written guidance — and we never miss an opportunity. Some of the recent communications with CMS include:

• A sign-on letter responding to a request for information on the recommended measure set for Medicaid-Funded Home and Community-Based Services. We urged them to work quickly to adopt a mandatory core set of HCBS measures.
• Comments to HHS in response to a proposed rule that would require HHS to retroactively review their regulations, opening the potential for sunsetting.
• Comments on the durable medical equipment, prosthetics, orthotics and supplies proposed rule (from both APTA alone as well as in partnership with AOTA and the American Society of Hand Therapists).
• Comments on the Medicaid, CHIP, and ACA Marketplace prior authorization proposed rule.
• Comments to CMS on next steps in developing cost measures for the Merit-based Incentive Payment System.
• Comments on the proposed inpatient rehabilitation facility Review Choice demonstration.
• Letter to CMS Regional Administrators outlining APTA's concerns with the Anthem AIM utilization management program.