The big picture: a bad plan for determining when services are delivered by a PTA or OTA
The US Centers for Medicare and Medicaid Services' (CMS) proposed physician fee schedule rule for 2020 includes provisions that would require providers to navigate a complex system intended to identify when outpatient therapy services are furnished by a physical therapist assistant (PTA) or occupational therapy assistant (OTA). If adopted, the plan would trigger a payment differential in 2022 based on how many minutes of services are provided by the PTA or OTA. (See this PT in Motion News story for a more detailed overview of the proposed rule.)

CMS proposes to accomplish this by way of new PTA and OTA modifiers (CQ and CO, respectively) to be included on claims beginning January 1, 2020. The proposal also requires providers to add a statement in the treatment note that explains why the modifier was or wasn't used for each service furnished that day. In short, the system is rooted in total minutes of service, and would require the use of the applicable modifier that would indicate when a PTA or OTA provided outpatient therapy services for 10% or more of the total time spent furnishing the service.

The proposal is more than just problematic—it's a threat to patient access to care, a vast overreach of CMS authority, and a documentation nightmare that flies in the face of CMS' "patients over paperwork" initiative to ease administrative burdens on providers. We laid out our concerns in a comment letter to CMS that describes the plan as "fundamentally flawed."

Some of what's being proposed, CMS reasoning behind it—and what we have to say

CMS: When the PTA participates in the service concurrently with the PT for a portion of total time, the modifier should be used when the minutes furnished by the therapy assistant are greater than 10% of the total minutes spent by the therapist furnishing the service, which means that the entire service would be subject to the 15% payment adjustment in 2022. This is being done to comply with Section 1834(v) of the Social Security Act.
APTA: The intent of the therapist assistant provisions in the Social Security Act was to better align payments with the cost of delivering therapy services given that therapist assistant wages are typically lower than therapist wages. It was not meant to apply an adjustment to a PT's services furnished when the therapist assistant provides a “second set of hands” to the therapist for safety or effectiveness.

The proposal completely ignores the efficacy of team-based care (CMS uses the term “concurrent“) and runs counter to the evolution—ostensibly supported by CMS—toward value-based care. "It is nonsensical to diminish reimbursement for services when safety precautions are implemented, and the overall value of the care is increased," we say in our letter. Bottom line: only services furnished in whole or in part independently by the assistant should count toward the 10% standard.

CMS: If the PTA and the PT each separately furnish portions of the same service, the modifier would apply when the minutes furnished by the PTA are greater than 10% of the total minutes—the sum of the minutes spent by the therapist and therapy assistant—for that service.
APTA: This proposal directly contradicts CMS' response to comments in the 2019 fee schedule final rule. In the rule, CMS explained how its claims processing system allows for the differentiation of the same procedure code when the same service or procedure is furnished separately by the therapist and assistant.

In our letter, we write that “the agency clearly is contradicting itself now, several months later, in proposing to require that the CQ/CO modifier apply when the minutes furnished by the assistant are greater than 10% of the total minutes—the sum of the minutes spent by the therapist and therapist assistant for that service, thereby not allowing for the same procedure code to be reported on 2 different claim lines.”

But that's just part of the problem. The system CMS is proposing for how providers arrive at this is anything but simple—in fact, we say that it's "outrageous that CMS expects therapy providers—particularly those who do not employ administrative staff and must perform all the coding and billing themselves in addition to delivering treatment to patients—to engage in division, addition, multiplication, and rounding merely to determine whether to affix a modifier to the claim."

CMS: Beginning in 2022, if the PTA services exceed the 10% limit, reimbursements will be cut by 15%.
APTA: The cuts pose a grave threat to the delivery of services, particularly in rural and underserved areas, especially when it's combined with the geographic indices that affect payment in these areas—on top of other potential reimbursement reductions in future years. We recommend that if CMS moves ahead with this proposal, it should exempt providers in rural and underserved areas from the requirements.

CMS: In addition to the use of new modifiers, providers will need to provide a written statement explaining why the modifier was or wasn't used—and it has to be done for each service furnished that day.
APTA: In our letter we call this plan "wholly unbelievable." Aside from the facts that the modifier proposal itself is extremely complicated and the extra documentation is not required by law, the addition of a statement requirement is clearly an undue administrative burden and a direct contradiction of the CMS "Patients Over Paperwork" initiative.

We write that the plan "conveys a sense that CMS is being vindictive toward outpatient therapy providers, creating a divisive environment for therapy providers enrolled in the Medicare program." Our comment letter goes on to provide 6 additional reasons why the documentation requirement is a bad idea, including the ways in which it complicates 15-minute timed billing, exceeds requirements of Medicare administrative contractors, and applies a standard to PTs, OTs, PTAs, and OTAs that isn't applied to physicians, physician assistants, and nurse practitioners.

What's next?
This letter is the first of 2 comment letters on the fee schedule that APTA will be providing to CMS in the coming weeks. Deadline for comments is September 27, and the final rule will likely be issued by November 1. APTA and several other providers associations will be meeting with CMS officials in mid-September to share concerns and provide recommendations.

You have an important role to play. Visit APTA's "Regulatory Take Action" webpage to access a customizable template letter on the PTA/OTA modifier, fill it in, and make your voice heard. It's easy—and crucial.

Stay tuned for additional opportunities for comment on other elements of the proposed rule.