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Federal Affairs Update

Friday, September 13, 2019   (0 Comments)
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Federal Affairs Update

·         Physician Fee Schedule

o   CMS estimates the 2020 PFS conversion factor to be $36.0896, a slight increase above the 2019 conversion factor of $36.04

o   2020 PFS estimated impact on the total allowed charges for physical therapy is 0%

·         KX Modifier

o   CMS is proposing revision to regulation text to clarify that the specified amounts of annual per-beneficiary incurred expenses are no longer applied as limitations but as threshold amounts above which services require, as a condition of payment, inclusion of the KX modifier

o   The use of the KX modifier confirms that the services are medically necessary as justified by appropriate documentation in the patient’s medical record

·         PTA/OTA Modifiers

o   CMS is proposing to amend the regulations for outpatient physical and occupational therapy services and for physical and occupational therapy services furnished by CORFs to establish as a condition of payment that claims for services furnished in whole or in part by an OTA or PTA must include a prescribed modifier and that services will not be considered furnished in part by an OTA or PTA unless they exceed 10% of the total minutes for that service beginning January 1, 2020.

§  CQ Modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant

§  CO Modifier: Outpatient occupational therapy services furnished in whole or in part by an OTA

§  In CY 2019 PFS final rule, CMS clarified that the CQ and CO modifiers are required to be used when applicable for services furnished on or after 1/1/2020, on the claim line of the service alongside the respective GP or GO modifier

§  2019 CMS finalized a de minimis standard under which a service is considered to be furnished in whole or in part by a PTA or OTA when more than 10% of the service is furnished by the PTA or OTA.

§  Situations identified by CMS when the therapy assistant modifiers apply

·         Therapeutic portions of outpatient therapy services furnished by PTA as opposed to administrative or other non-therapeutic services that can be performed by others without the education and training of OTAs and PTAs

·         Services wholly furnished by the PTAs without the PT

·         Evaluative services that are furnished in part by the TPA. Keep in mind that PTAs are not recognized to wholly furnish PT evaluation or re-evaluations

§  Situations identified by CMS when the therapy assistant modifiers do NOT apply

·         PTAs furnish services that can be done by a PT Tech

·         PT exclusively furnish services without the involvement of the PTAs

§  CMS proposes to apply the CQ/CO modifier policies to all services that would be billed with the respective GP or GO therapy modifier

§  When deciding whether the therapy assistant modifiers apply

·         If the PTA participate in the service concurrently with the PT for only a portion of the total time that the PT delivers a service, the CQ modifier applies when the minutes furnished by the PTA are greater than 10% of the total minutes spent by the PT furnishing the service

·         If the PTA and the PT each separately furnish portions of the same service, the CQ modifiers 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 PT and PTA- for that service

§  Documentation Requirements

·         Beginning 1/1/2020, CMS proposes to add a requirement that the treatment notes explain, via a short phrase or statement, the application or non-application of the CQ modifier fro each service furnished that day

·         This proposal extends to the untimed services also

§  Feedback

·         CMS seek comment regarding the appropriateness to require documentation of minutes, explanation, and administrative burden

·         Dry Needling (CPT codes 205X1 and 205X2)

§  CMS is proposing a work RVU of 0.32 for CPT code 205X1. Needle insertion without injection, 1 or 2 muscles with 10 minutes of intraservice work time

§  RVU of 0.48 for needle insertion without injection 3 or more muscles with 15 minutes intraservice work time

·         Merit-based Incentive Payment System

§  2020 will have changes to the PT/OT measure set, including the addition of new measures and removal of others

§  MIPS eligible clinicians with a final score = 45 points would receive a neutral MIPS payment adjustment.



·         Workforce Diversity: Legislation introduced in the US House seeks to provide $5 million/year in scholarships and stipends aimed at increasing the number of students from underrepresented populations in PT and other allied health education programs. The Allied Health Workforce Diversity Act of 2019

·         Prior Auth: Legislation aimed at improving success to health care for older Americans through reducing administrative burdens on providers will be a focus of AOTA advocacy in August.  Known as the “Improving Seniors’ Timely Access to care Act of 2019. APTA staff will add information to the Legislative Action Center this month for members to use to advocate in support of this legislation

·         Proposed 2020 Home Health Rule: CMS intends to move forward with the new payment system for home health beginning in 2020. The plans are accompanied by other changes that include allowing for maintenance therapy to be furnished by PTAs, providing a payment “add-on” for rural home health care, and adopting an APTA supported notice of admission requirement to avoid duplicate billing. The new payment system known as the Patient-Driven Groupings Model moves care from 60-day to 30-day episodes and eliminates therapy service-use thresholds. 

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