Current Payment News

NCCI Edit information - December, 2020 

CMS Releases Coding Edits With Possible Good News for PTs CMS has released the list of Medicare National Correct Coding Initiative procedure-to-procedure edits that will take effect Jan. 1, 2021. Many of the PTP edits for common physical therapy code pairs have been deleted; APTA staff are currently reviewing the files in detail to identify all the changes. One early finding: We’ve determined that the problematic edits that prohibited the billing of codes 99281-99285 with codes 97161-97164 have been deleted. We’ll share more detailed information about all the changes as soon as possible. The updated list of PTP edits can be found at the CMS NCCI coding edits page.

Final Rule CY 2021 2 Big Picture Takeaways and an overview:

Big picture, takeaway 1: Saying its options are limited by law, CMS is moving ahead with a severe cut to physical therapist services. Despite intense pressure from a long list of professional associations, patient advocacy groups, and members of Congress, the U.S. Centers for Medicare & Medicaid Services has released a final physician fee schedule for 2021 that results in significant cuts to many codes used by nearly three dozen professions, with physical therapy, occupational therapy, and speech-language pathology facing an estimated 9% overall reduction. According to CMS, those reductions had to be made in order to increase payment for evaluation and management codes, known as E/M codes, while maintaining budget neutrality required by law. ). It's now up to Congress: CMS has finalized cuts, making it more important than ever to urge lawmakers to support H.R. 8702. The cuts proposed by CMS in 2019 will take effect Jan. 1, 2021, but a bill in Congress could offset the damage. Contact your legislators to advocate for adoption of the Holding Providers Harmless From Medicare Cuts During COVID-19 Act of 2020, and join us for a virtual #FightTheCut rally on Dec.  

In this review: CY 2021 Revisions to Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Medicare Policies (final rule), CMS fact sheet Effective date: Jan. 1, 2021

Big picture, takeaway 2: CMS says it doesn’t have authority to permanently add PTs and PTAs as authorized Medicare providers for real-time telehealth services (but will allow e-visits, virtual check-ins, and remote assessment of video or images by PTs). The rule will allow these three forms of non-face-to-face physical therapy services to continue to qualify for payment — approaches that were among the first to be permitted for PTs and facility-based therapy providers in the early days of the coronavirus public health emergency. For now, however, opportunities for real-time telehealth services once again will be unavailable to PTs and PTAs after the end of the PHE.

Both proposals from CMS highlight the need for federal legislation that allows for changes advocated by APTA and multiple patient and stakeholder groups. APTA is urging members to join in its efforts to push for congressional support of H.R. 8702 to stop the detrimental cut from taking effect.

The 9% Cut

The final rule implements cuts by way of a decrease in the conversion factor, from its current $36.0986 to $32.4085. That's an important change, because adjusting the conversion factor is the tool CMS is using to maintain budget neutrality while increasing payment for E/M codes.

Here's how it works: To arrive at a payment amount, components of the fee schedule — work, practice expense, and malpractice RVUs — are adjusted by practice cost indices to account for geographic variations in furnishing services. Next, those adjusted RVUs are combined, and the conversion factor is applied to arrive at a final amount. If revisions to the RVUs cause expenditures for the year to change by more than $20 million, CMS must make adjustments to ensure that overall expenditures do not increase or decrease by more than $20 million. For CMS, decreasing the conversion factor is the only way to increase payment for E/M codes and maintain the budget neutrality mandated by Congress.

The reduced conversion factor translates to a combined estimated 9% drop in physical therapy, occupational therapy, and speech-language pathology payment. Three dozen health professions are facing payment reductions.

In a joint statement released just after the proposed fee schedule was announced, APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association wrote that the reductions "will severely damage patient access to the services our members provide across the care continuum." The organizations call on Congress to prevent a crisis in access to care by creating a legislative remedy.

“Our members serve a critical role in the health and vitality of this nation, frequently evaluating and treating older adults with physical, cognitive, communication, psychosocial, hearing, and balance disorders," the associations wrote. “Rehabilitative and audiologic services may not be available to Medicare beneficiaries, nor to millions of other patients, if therapy practitioners, audiologists, other members of the clinician team, and institutional-based providers are unable to sustain these cuts and are forced to close their doors.”

Telehealth in Physical Therapy

Despite APTA’s successful advocacy that has allowed PTs and PTAs to engage in services delivered via real-time telehealth during the public health emergency, CMS doesn't provide a way for that ability to remain once the emergency ends. CMS states in the final rule that at the conclusion of the PHE for COVID-19, payment for Medicare telehealth services will once again be limited by the requirements of section 1834(m) of the Social Security Act. 

In the proposed rule, now made final, CMS created a third category of criteria for adding services to the Medicare telehealth services list on a temporary basis — a category that includes services for which there is likely to be clinical benefit when furnished via telehealth, but for which there is not yet enough evidence to permanently add the services under Category 1 or Category 2. Any service added under Category 3 will remain on the Medicare telehealth services list through the calendar year in which the public health emergency ends. Initially, physical therapy codes weren't included in the temporary Category 3 list; due to APTA advocacy efforts the final rule does include the following codes: 97161- 97164, 97110, 97112, 97116, 97535, 97750, 97755, 97760, and 97761.

It’s important to keep in mind that despite the addition of these codes to the telehealth list on a temporary, Category 3 basis, that doesn't mean PTs and PTAs will be eligible to furnish and bill for telehealth services through the end of a calendar year should the PHE ends before that. Bottom line: Barring congressional action — and even with these codes added to this list on a temporary basis — during the time between the end of the PHE and the remainder of the calendar year in which the PHE ends, telehealth services can only be furnished by a PT if billed incident to the professional services of a physician or practitioner who is authorized to furnish and bill for telehealth services, provided that the “incident to” requirements are met.

Clarification of Existing PFS Policies for Telehealth Services
The final rule also clarifies that if audio/video technology is used in furnishing a service when the beneficiary and the practitioner are in the same institutional or office setting, then the practitioner should bill for the service furnished as if it was furnished in person, and the service would not be subject to any of the telehealth requirements under the Medicare telehealth statute and regulations.

Direct Supervision Established Through Virtual Presence
In an effort to limit COVID–19 exposure for the duration of the PHE, in the spring, CMS adopted an interim final policy that revises the definition of direct supervision to include virtual presence of the supervising physician or practitioner using interactive audio/video real-time communications technology. This temporary policy applies to private practice PTs and PTAs.

In the proposed fee schedule, CMS proposed to extend this policy until the end of the calendar year in which the PHE for COVID-19 ends — an expansion from the original policy set in place at the beginning of the PHE. CMS finalized that proposal, which means direct supervision can be provided using real-time, interactive audio and video technology through, at the very earliest, Dec. 31, 2021. If the PHE extends beyond 2021, the cutoff for remote supervision allowances would move to the end of whatever year the PHE ends.

CMS also clarified that telehealth services may be furnished and billed when provided incident to a distant site physicians’ (or authorized NPP’s) service under the direct supervision of the billing professional provided through virtual presence.

Communication Technology-Based Services
The final rule allows for forms of remote services by PTs on a permanent basis, designating them as “sometimes therapy” codes — namely, e-visits (G2061-G2063), remote assessments of recorded content or images from an established patient (G2010), and virtual check-ins (G2012). CMS states in the final rule that it is replacing HCPCS codes G2061-G2063 with CPT codes 98970-98972. CMS also developed HCPCS codes identical to the existing virtual therapy codes (G2010 and G2012). These are G2250 and G2251, respectively.

Also Notable in the Final Rule

  • PTAs and OTAs are permitted to provide maintenance therapy in Part B settings. In another change first adopted during the public health emergency thanks to APTA’s advocacy, CMS is adopting a permanent change that allows PTs and OTs to delegate maintenance therapy to their supervised assistants in Part B settings. PTs still are expected to abide by existing rules that require use of the CQ modifier when services are provided "in whole or in part" by the PTA.
  • Payment for physical therapy evaluations and reevaluations get a bump — but not enough to offset the overall damage done by the lower conversion factor. CMS acknowledges that physical therapy CPT codes related to evaluation and reevaluation are similar to the E/M visit code set, and will increase the work RVU for evaluation codes 97161, 97162, and 97163 from 1.2 to 1.54. The work RVU for reevaluation (97164) rises from 0.75 to 0.96.  Bottom line: Despite the conversion factor reduction, in the case of these codes, payment would increase in 2021. But that's by far the exception: For many other codes in the physical therapy code set the lowered conversion factor ultimately results in reductions in Medicare payment.
  • Codes associated with remote physiologic monitoring would remain out of reach for PTs. Despite persistent advocacy to the contrary, CMS is sticking to its opinion that CPT codes 99091, 99453, 99454, 99457, and 99458 — all associated with remote physiologic monitoring — are E/M codes that can be billed only by providers who can bill for E/M services. PTs aren't on that list.
  • Flexibility with medical record documentation. CMS clarified that PTs who are authorized to furnish and bill for their professional services may review and verify (sign and date) the documentation in the medical record for the services they bill, rather than re-document notes in the medical record made by therapy students or other members of the medical team. While any member of the medical team may enter information into the medical record, only the reporting therapist may review and verify notes made in the record by others for the services the reporting therapist furnishes and bills. The information entered into the medical record must support that the furnished services are reasonable and necessary.
  • KX modifier threshold amount for 2021. 2021 Annual Update of Per-Beneficiary Threshold Amounts: CMS has released the 2021 Annual Update of Per-Beneficiary Threshold Amounts. For CY 2021, the KX modifier threshold for physical therapy & speech-language pathology services combined is $2,110; the KX modifier threshold for occupational therapy is $2,110. The targeted medical review threshold remains at $3,000 until CY 2028, at which time Medicare will update it based on the Medicare Economic Index.
  • The MIPS portion of the rule will be published in the coming days




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