As the payment landscape for 2019 comes into focus, it's becoming clear that physical therapists (PTs) will continue coding evaluations according to a 3-tiered system based on patient complexity. It's also clear that for now, at least, Medicare will not be using a tiered payment system, even as some commercial payers and state Medicaid plans adopt systems that reflect the complexity levels. Through it all, APTA continues to offer resources that help to reinforce accurate and consistent coding.
CMS has indicated that its flat reimbursement policy, opposed by APTA from the start, will allow the agency to evaluate the distribution of utilization of the tiered codes in order to better determine the payment model. That distribution is beginning to come into focus: APTA research into nearly 4 million evaluations billed by providers across settings has revealed that 47% of evaluations were billed in the low-complexity category, 45% in the moderate-complexity category, and 8% in the high-complexity category.
"At this point in time we have a sampling of baseline data that reflects practice in the first year of the tiered codes," said Alice Bell, APTA senior payment specialist. "CMS is also looking at this data and has indicated that they feel it will take 2 years of data to have an accurate representation. That means it's important that coding remain accurate and consistent."
In its latest efforts to help underscore the importance of continued accurate coding, APTA produced a series of free podcasts on the CPT evaluation codes. The 5-part series covers a general overview of the coding change and addresses common questions related to determining levels of stability, documenting elements, the relationship of examination time to code selection, and coding in reevaluation. With episodes ranging from 5 to 8 minutes in length, the individual podcasts are convenient for quick listens on the go or during breaks at the clinic.
"APTA is committed to supporting physical therapists through this transition to tiered coding in order to ensure that code selection truly reflects the level of complexity of the evaluation," Bell said. "Before we see further changes in reimbursement based on the tiered codes we want to make sure therapists have the tools and resources necessary to make the appropriate code selection. Accuracy in coding is critical if we are to make a compelling case for achieving our long-term goal of establishing reimbursement rates that truly reflect patient complexity."
