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Payment and Reimbursement

Payment Resources

January 15, 2021 - Moda Health updates Telehealth and Telemedicine Expanded Services for COVID-19: Effective January 1, 2021, the Oregon Health Authority, Public Health Division, Maternal and Child Health Section is temporarily adopting OAR 333-006-0170 to support appropriate response during an outbreak or epidemic of an infectious disease. The rule allows Newborn Nurse Home Visiting services (98960, 99501, 99502) provided under OAR 333-006-0120 to be provided by telehealth during the COVID-19 pandemic to protect the health and safety of the home visiting workforce and families receiving the services. (OHA24, OHA25)

Added to Misc Services: 93750 - Interrogation of ventricular assist device. Please see Policy and Version Compare feature on your Landscape for more details.

Telehealth And Telemedicine Expanded Services for COVID-19

January 6, 2021  - Update to CMS Payment Calculations Further Eases Impact of Cut
The new conversion factor released by CMS helps to offset the impact of fee schedule reductions for PT providers

What began as a projected 9% cut in payment to PTs under Medicare and was later reduced to an estimated 3.6% cut may be whittled down even further thanks to a recently announced change to how payment is calculated. The change comes by way of an adjustment to the conversion factor, the multiplier applied to relative value units to determine Medicare Part B payment amounts. That figure changed from CMS' planned $32.41 (precise number: $32.4085) rate to $34.89 ($34.8931) for 2021.

The new conversion factor is still a drop from the 2020 conversion factor of $36.09 ($36.0896), but one that's far less severe than originally approved — a 3.32% decrease compared with the 10.2% reduction in the final fee schedule.

The result: The smaller cut, coupled with targeted provisions in a spending and COVID-19 relief bill enacted in late December, will help to blunt the effects of changes adopted by CMS that threatened to reduce physical therapy payment by an estimated 9%. Even before factoring in the changes to the conversion factor, the congressional action reduced the effects of the cuts from 9% to an estimated 3.6% for PTs.

How It Works Out for Payment

In some coding situations, the combination of factors may result in cuts less than the estimated 3.6%. For example, payment for therapeutic exercise (CPT code 97110) will drop by an average of 3.3%, from $31.40 in 2020 to $30.36 this year, with manual therapy (97140) seeing a similar percentage decrease, from $28.87 in 2020 to $27.91 in 2021. Neuromuscular reeducation (97112) drops by 2.35% (from $36.09 to $35.34), while CPT code 97530, for therapeutic activities, sees a 2.45% decrease from its 2020 level of $40.42 to $39.43 in 2021.

In a few instances, the new payment levels could even result in slight increases, particularly for PTs conducting an evaluation or reevaluation. For example, in 2020, use of evaluation CPT codes 97161-97163 resulted in a payment of $87.70; that payment increases to $101.89 in 2021. Similarly, payment for reevaluation CPT code 97164 will also increase this year, from $60.30 in 2020 to $69.79. (Note: actual amounts vary by locality).

Increases to the office/outpatient evaluation and management visit codes billed by primary care and some specialty physicians were at the heart of payment cuts to some three dozen professions that CMS says it was forced to implement to maintain budget neutrality. The CMS plan sparked an intensive advocacy effort at both the agency level and on Capitol hill, including historic levels of participation from APTA members and supporters fighting the cuts.

Cuts Still "Unsustainable"

While the new conversion factor is good news for PTs, the damage inflicted by CMS remains — and must be addressed, according to Kara Gainer, APTA's director of regulatory affairs.

"The updated conversion factor and COVID relief provisions helped us partially dig out of the hole we were put in by CMS, but even with those wins, we're still facing cuts that are simply unsustainable and damaging to patient access to needed care," Gainer said. "We need not only to continue to advocate for more relief, but also to engage in a serious dialogue about whether the current physician fee schedule system is an antiquated response to the current demands of our health care environment."

The new conversion factor will be integrated into the 2021 version of APTA's Fee Schedule Calculator. Those changes should be loaded into the system in the coming weeks. APTA will share news of the updated calculator when it's available.

December 7, 2020 - Win: CMS Will Lift Several Code Pairing Restrictions

December 1, 2020

URGENT: Call Your Members of Congress NOW to Prevent Medicare Cuts

As the end of 2020 nears, we need your help now more than ever to fight the proposed 9% cut to physical therapy services under Medicare and make sure it does not go into effect on January 1, 2021. We need you to take a few minutes and call your members of Congress today and ask them to urge congressional leadership to include H.R. 8702, a bill introduced by Rep. Bera (D-CA) and Rep. Bucshon (R-IN), in critical upcoming end-of-year legislation.

Step One: The Ask

The ask for your members of Congress is to speak to party and committee leadership on the Medicare cut. This will be different based on the chamber and party of your legislators. Please be mindful of who you’re talking to and amend your ask accordingly. Please respond to this email if you have any questions or would like any guidance.

  • If your Representative is a Republican, request that they speak to Rep. McCarthy, Rep. Brady, and Rep. Walden
  • If your Representative is a Democrat, request that they speak to Speaker Pelosi, Rep. Neal, and Rep. Pallone
  • If your Senator is a Republican, request that they speak to Sen. McConnell and Sen. Grassley
  • If your Senator is a Democrat, request that they speak to Sen. Schumer and Sen. Wyden

Step Two: Call Your Members of Congress

Your Legislator Contact Information

  • House: Congressman Greg Walden (202) 225-6730
  • Senate 1: Senator Ron Wyden (202) 224-5244
  • Senate 2: Senator Jeff Merkley (202) 224-3753

Step Three: Call Script (please be mindful of the capitalized areas, where you need to customize based on the office you are speaking with).

Hello! My name is YOUR NAME from YOUR CITY AND STATE. I would greatly appreciate your help if YOUR MEMBER OF CONGRESS could please urge RELEVANT CHAMBER AND PARTY LEADERSHIP to incorporate H.R. 8702 in the upcoming continuing resolution or any legislation moving through Congress during the lame duck session in order to prevent further damage and instability during this difficult time for patients and providers.

ADD IN A TWO-SENTENCE PERSONAL STORY ON HOW THE CUTS WOULD IMPACT YOU/YOUR BUSINESS/YOUR PATIENTS

I appreciate your work and thank you for your time today.

END OF CALL SCRIPT

We appreciate your help and resilience as we continue to #FightTheCut. We are so grateful for your advocacy on this issue that would have far-reaching and long-term repercussions to the profession and the patients we serve.

September 19, 2020

Post-Payment Reporting Requirements

SEPTEMBER 14, 2020

On Wednesday, September 2nd, Center for Medicare Services (CMS) announced that they decided to reverse their position on the 59 modifier and code pairing restrictions and reinstate their use starting October 1st, 2020. Firm advocacy against this policy was helpful in reversing this same ruling in April, 2020, which the APTA and other healthcare associations played a large role in. Time appears to be repeating itself as CMS did not include these rulings in paperwork sent to healthcare associations across the country, leaving no time for edits, now a second time. For example, with this new policy, CMS will not pay for manual therapy (97140) when billed on the same day as an evaluation unless it is billed with the 59 modifier. This is clearly another barrier to practice and reimbursement and as with many CMS rulings, this poor healthcare policy is likely to reach outside of just CMS.

For the APTA's full announcement and breakdown, please click here.For an infographic on how to properly use the 59 modifier, please click here.

Interested in advocating for yourself and your patients, family and friends? Sign up for the APTA's Advocacy Network as an APTA member below.

OR, attend a Government Affairs Committee meeting and get plugged in!

 

JUNE 1, 2020

Win: CMS Says SNFs, Hospitals, HHAs, Rehab Agencies, Other Institutional Settings Can Bill Telehealth Outpatient Therapy Claims. The clarification from CMS applies to settings that use institutional claims such as UB-04.

WEDNESDAY, APRIL 22, 2020

Don't forget to use the CQ modifier if more than 10% of a service is furnished by a PTA.

TRICARE, the health insurance system used throughout the military, announced that it has officially revised its policy manual to recognize PTAs (and occupational therapy assistants) as authorized providers, outlining the rules and requirements governing assistant qualifications, scope of practice, supervision, and reimbursement.

Now it's up to TRICARE contractors to do the same within approximately 30 days.

As reported earlier, beginning with date of service on April 16, PTAs are recognized as authorized providers under TRICARE and thus eligible for reimbursement for covered services rendered to TRICARE beneficiaries.

Take note: The CQ modifier must be appended to the claim when more than 10% of an outpatient physical therapy service is furnished by the PTA. Check out APTA’s Quick Guide to Using the PTA Modifier.

The presence of the modifier shouldn't impact claims processing. However, if claims are denied, they may need to be resubmitted if the claims are sent to contractors before they fully implement the change.

http://www.apta.org/PTinMotion/News/2020/04/22/TRICAREManualUpdatePTAs/

 

IMPORTANT UPDATE: PT Compact Commission, APTA, FSBPT, and other Allies Successfully Resolve Medicare Issue

In late 2019, the Physical Therapy Compact Commission (PTCC) staff learned that an individual with a compact privilege was not allowed to enroll as a provider with Medicare in a member state and therefore could not make claims for services.

Since that time, the American Physical Therapy Association (APTA), PTCC, and FSBPT have been working closely to resolve the issue. The APTA has been instrumental in helping the PTCC determine the extent of the issue and coordinate a strategy to resolve it as quickly as possible.

The PT Compact Commission recently received great news from the Centers for Medicare and Medicaid Services (CMS) officials that their general counsel determined that the compact privilege is considered a valid, full license for purposes of meeting federal licensure requirements. They are providing guidance to the Medicare Administrative Contractors (MACs) to accept compact privileges moving forward and to re-open any applications that were denied under this basis and continue processing. CMS is also drafting an MLN Matters article that will provide guidance about the Medicare enrollment process to PTs and PTAs practicing with compact privileges. Although there is not an exact timeline on the publication of the article and the notification to MACs is expected to take at least a few days, this is obviously fantastic news for PTs and PTAs!

The successful resolution of this important issue demonstrates the power of health care organizations working together. To receive more updates on the Medicare issue and other happenings at the PTCC be sure to sign up for their email distribution list

The APTA Payment section has information for the following topics:

More information on Federal Workers' Compensation:

www.workerscompensation.com

More Information on Oregon Workers' Compensation:

 www.wcd.oregon.gov/rdrs/mru/mpindex.html

 

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