Payment

Current Payment News 

April 2024

Adapted from March 22, 2024 APTA Friday Focus – Payment:

Change Healthcare Cyberattack Updates

Providers and patients continue to deal with the effects of the massive Feb. 21 cyberattack, the largest health care hack to date. Here's a roundup of useful information, including links to Change and UnitedHealth resources, HHS announcements, media coverage, and more. 

Aetna Launches PTA Differential

After putting the move on hold for three months, the insurer implemented the reduction March 1. 

Spending Deal Reached: Includes Some Relief From Fee Schedule Cuts

The package includes a 1.68% boost to the fee schedule but falls short of totally eliminating the cut to dozens of providers 

Going Straight to the Source: Direct-to-Employer Services

From APTA Magazine: Direct-to-employer physical therapy companies take out the insurance middleman.

February 2024

NHP partnered with Evolent Health to manage services for PT, OT, SLP through National Imaging Associates (NIA)

• RI APTA Payment Committee is engaging with NHP against these changes that add administrative burdens to providers and ultimately impact access to care.
• Reach out to Yvonne Swanson, RI Payment Committee Chair with your concerns yswanson@highbarhealth.com

Know your rights! Prior Authorization Win: CMS Finalizes Tighter Payer Rules

Review of Policy Key Points:

• All services under Evolent’s solutions will require prior authorization as of April 1^st.
• Verification for rendering services for new and continued care must be obtained by signing in on Evolent’s website, or calling Evolent at 1-877-469-7949
• FAQ’s click here and Provider Education Webinars are scheduled for are March 27, March 29, and April 4, 2024

Want help calculating Medicare payments? …APTA’s Fee Schedule Calculator for 2024 is now available!

2024 Fee Schedule Calculator Now Available to APTA Members

“Great tool that’s easy to use!”

Reflects where payment stands as of Jan. 19th. If Congress makes changes, the tool will be updated.

Medicare Physician Fee Schedule cuts of 3.4% continue….We need your help TODAY! 

Congress kicked the can down the road in January giving ALL stakeholders more time to voice their concerns to local legislators about the impact of these cuts.

Support H.R. 6683 through the APTA Patient Action Center or Legislative Action Center.  It’s fast and easy!  

November 2023

Local Payor Updates: 

Huge win! Blue Cross Blue Shield Increases max allowable per visit! : Sign in to your BX account for detailed description

Blue Cross Blue Shield Removes referral requirements effective Jan. 1^st 2024 for PT and OT services under the following products:  

• All Medicare Advantage Plans, Blue CHiP Direct Advance, Blue CHiP w/Flex, Network Blue NE, Network Blue NE Options and Blue Choice NE

Summary of CMS' Physician Fee schedule and final rule adapted from APTA 2024 PFS and Final Rule update 

• Fee schedule ~3.4% reduction to the conversion factor. – APTA advocating with congress to reduce in full to keep PT's whole.  $240.00 deductible,  Threshold for use of KX modifier for PT/SLP $2,330.00 , Medical Review Threshold remains at $3000.00 through 2027   
• CMS' Quality Payment Program  MIPS Rule:
  • Incorporates a new APTA recommended  MVP MIPS Value Pathway based on musculoskeletal care with a new cost measure PTs can use on low back pain. 
  • CMS will no longer exempt PT practices of 16 or more clinicians from the promoting interoperability category which requires practices to have a certified electronic health records technology in place for at least 6 months of  2024. This change does not apply to hospital based clinicians and clinicians in small practices

• Telehealth: No changes in codes.  Under final rule PT's can participate in TH in private practice settings by uing the same 95 modifier. 
• PTA supervision requirements – remain at "direct supervision" for 2024 in private practice settings. The final rule extends virtual supervision of PTAs and OTAs through the end of 2024, and finalizes a general supervision-only requirement for PTAs performing remote therapeutic monitoring regardless of setting. 

• New Caregiver Training Codes: Allows for PT's OT and SLP's to bill for providing training to caregivers when a patient with a functional deficit is not present. They are not subject to MPPR and cannot be used with Telehealth. 97550 initial 30 min. , 97551 ea. Additional 15 min. , 97552 Group  
• Also in the final rule, CMS responded to a criticism from APTA that requiring 16 days of monitoring for codes 98980 and 98981 — treatment management codes that account for time spent in a calendar month — isn't appropriate for these types of services. CMS agreed, and clarified that the 16-day collection requirement doesn't apply to the two codes

October 2023

APTA RI has an active Payment Committee. This committee advocates for local payment issues and monitors important federal issues to share with members.   Recently this committee advocated against NHP’s Integrity policy shift to a 24 visit cap. The appeal has resulted in reversal!  This reversal improves access to care by eliminating the cap and arduous process of appeal while maintaining the initial 24 visits before prior authorization is required.    Full policy here.  Federal Payment Updates Adapted from APTA Friday Payment Focus:   The Proposed '24 Fee Schedule: Takeaways From APTA's Comments to CMS APTA seized the opportunity to address the good, the bad, and the unclear.   Aetna Will Adopt PTA Pay Differential The 15% reduction, set to begin Dec. 1, would mimic CMS cuts adopted in 2022. APTA is pressing Aetna to reconsider.   CMS Enters New Territory, Proposes Staffing Requirements for LTC Facilities Most nursing homes would fall short of the requirements, which also include more detailed facility assessments and a constant RN presence.

 July 2023

 April 2023

Navigating Insurance  – APTA RI Payment Committee Tips for success:   

• Medicaid Renewal 2023 – RIAPTA has compiled resources to assist Practices help patients stay covered – Please review this resource  
• UnitedHealth Tip
  • Community Plan:  To avoid denials, a taxonomy code is required in box 33b on the 1500 Form in order for claim to be processed
  • Commercial Plans:  Out of network denials could be occurring due to UHC system glitch – f/u with your representative if affecting your claims.
• Blue Cross - Anthem 
  • Out of State Authorization/Benefits: Use the 1-800- Number to assist with benefit determinations.

Adapted from APTA’s Friday Focus: Remote Therapeutic Monitoring: APTA Updates

• Updated RTM  practice resource, advocated for continued patient access to RTM, and alerted MACs to denials they're making in error.

Cigna

On 3/2/23 APTA met with Cigna leadership.  These meetings will be held 2x a year with the next in fall 2023. ASH leadership also joined at the suggestion of Cigna.  Highlights are noted below:

1. Direct access/ PT first:  APTA expressed concern that Cigna medical policies do not clearly facilitate direct access. Cigna indicated active support for direct access and was surprised that providers were not clear on the need for a referral. Cigna understands the value of physical therapy and will continue to develop programs that enable conservative management. Cigna will review current stance on direct access and maybe add more communication to market, so policy is clear.
2. PT in prevention and wellness

Discussed PT in prevention and wellness including the annua visit. Cigna relayed that coverage is benefit driven and both ASH and Cigna asked if there was evidence demonstrating that the annual visit is cost effective? There is currently no evidence and or expressed interest in implementing or conducting a pilot to collect data.

3. Value based care opportunities

Cigna is primarily involved with surgical value-based models that extend from admission to hospital discharge. Possibly in the future they may consider include pre/post op PT, but no plans are imminent.

4. Future of Telehealth

Both ASH and Cigna expressed support for continued remote services. Cigna: is looking at all aspects of telehealth including Remote Physiological Monitoring. 

NIA/Magellan

National Imaging Associates: Physical Medicine – Guideline  Pending - High Importance Update

Issued a new version of the document. Review date: 07/01/2023. Next review date (est.): 07/01/2024

View Full Policy - PDF      View Full Policy - Payer Website

UHC

Upon a change in the UHC association leadership team, the meetings were postponed until the new staff was on boarded. The next meeting is currently planned for June 2023. 

ASH- American Specialty Health

ASH Newsletter: https://www.ashlink.com/ash/WCMGenerated/JanFeb2023_RS_online_tcm17-213294.pdf 

AIM

In March 2023, AIM Specialty Health_® transitioned to Carelon Medical Benefits Management Inc. Per Anthem, “This transition is a name change only, and there will be no process changes”.  If providers inquire, please let them know to check their February 2023 Anthem newsletter for the announcement.  Here is info found during a google search.

• https://www.carelon.com/about-us?gclid=Cj0KCQiA6fafBhC1ARIsAIJjL8mLS9Jt4kXQBpLCPzLv6gqE45wDYLuRspz8LOPrtbYF-Uvd31Np1cYaApf9EALw_wcB&gclsrc=aw.ds
• https://www.xifin.com/resources/industry-news/202207/anthem-launches-carelon-wellpoint-ahead-elevance-health-rebrand,
• https://www.premera.com/ak/provider/news/reminders-updates/aim-transitions-to-carelon/
• https://www.fiercehealthcare.com/payers/elevance-healths-profits-dipped-949m-q4-revenue-grows 

SecureCare (SC)

On 3/21 APTA and the pay chairs from MN and MI met to discuss the status of the SC implementations in their state. On 3/28 APTA met with SC to review the rehab program.

Additional Resources: 

Prior Auth

https://www.beckerspayer.com/payer/were-not-deaf-to-the-complaints-big-payers-moving-to-cut-prior-authorization-requirements.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter 

https://www.beckerspayer.com/payer/unitedhealthcare-cutting-20-of-prior-authorizations.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=0828A7664990B0E 

https://www.healthcaredive.com/news/unitedhealthcare-prior-authorization-changes-provider-reactions/646399/?utm_source=Sailthru&utm_medium=email&utm_campaign=Issue:%202023-03-30%20Healthcare%20Dive%20%5Bissue:49223%5D&utm_term=Healthcare%20Dive 

https://www.beckerspayer.com/payer/5-reactions-to-unitedhealthcares-prior-authorization-cuts.html?utm_campaign=payer&utm_source=website&utm_content=latestarticles&origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=0828A7664990B0E 

https://www.beckerspayer.com/payer/89-of-physicians-say-prior-authorization-leads-to-worse-patient-outcomes-ama-survey-finds.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=0828A7664990B0E#:~:text=M%26A-,89%25%20of%20physicians%20say%20prior%20authorization%20leads%20to,patient%20outcomes%2C%20AMA%20survey%20finds&text=The%20majority%20of%20physicians%20say,from%20the%20American%20Medical%20Association. 

https://www.beckerspayer.com/payer/8-updates-on-prior-authorization-2.html?origin=PayerE&utm_source=PayerE&utm_medium=email&utm_content=newsletter&oly_enc_id=0828A7664990B0E

January 2023

Neighborhood Health Plan -Integrity: Removed Prior Authorization requirement for PT and OT beyond 24 sessions per calendar year for INTEGRITY members, effective Jan. 1st 2023  

More information: Physical-and-Occupational-Rehabilitation-Services-eff-1.01.23.pdf  

ASH-American Specialty Health

New clinical guidelines were issued at the end of the year and can be found here 

Article: 

CMS rule aimed at improving Medicare Advantage draws praise | Healthcare Dive

Payment Resources:

State Payer Advocacy Resource Center (SPARC):

A joint initiative of payer resources brought to you by APTA and APTA Private Practice Section                                      

August 2022

Member initial notice on the new Cigna policies . The items in italics were copied from the Cigna announcements: 

As you are probably aware, Cigna has recently made notice of their intent to impose a 4 unit per visit limitation and a 15% payment differential for services provided by a PTA effective October 15^th with TX,  KY, CO, and OH starting on November 1^st.  New Cigna policies are shown below and described here: 873827_ExternalHCP_Template2014_V2 (mercyoptions.net) and CHCP - Resources - Policy Updates July 2022 (cigna.com). 

PTA differential: Modifiers CO and CQ reimbursement reduction for physical or occupational therapy assistant services Reimbursement for claims submitted with modifiers CO and CQ for services provided by a physical therapy (PT) or occupational therapy (OT) assistant will be reduced by 15 percent. This update more closely aligns with industry standards, including the CMS National Physician Fee Schedule, which reimburses these services at 85 percent. We will update the Health Care Common Procedure Coding System (HCPCS) National Level II Modifiers reimbursement policy to reflect this change. This update is effective for dates of service on or after October 15, 2022 (in all states except TX, KY, CO, and OH where it starts on November 1^st). 

4 unit per visit limit:  Physical therapy, occupational therapy, and chiropractic claims for greater than four units (60 minutes) of timed service. The portion of a physical therapy (PT), occupational therapy (OT), or chiropractic claim that is greater than four units (60 minutes) of timed, short-term rehabilitation services per patient, per day, per provider will be denied as being not medically necessary. We will update the Omnibus Codes (0504) medical coverage policy to reflect this change. This update is effective for dates of service on or after October 15, 2022 (except in TX, KY, CO, and OH where it starts on November 1^st). 

APTA has been in contact with Cigna and is gathering details on the rollout. Here is what we know thus far:

1. a.      Cigna direct agreements including outpatient hospital facilities are impacted.
2. b.      Cigna out of network providers will be impacted by the policy changes.
3. c.      There are no plan exclusions.
4. d.      There will be negligible impact for providers contracted with ASH (American Specialty Health). ASH will not implement the PTA/OTA modifiers and the four unit per visit limitation of timed codes is already built into the ASH utilization review process.
5. e.      There is an exception process in place based on medical necessity review with appeal rights for the 4 unit per visit limitation.
6. f.       ASH notified providers on 8/1/22.
7. g.      Cigna notified providers around 8/3/22. 

APTA PTA differential and CQ modifier resources are found here: https://www.apta.org/search?Q=PTA+differential&sort=0 and https://www.apta.org/apta-magazine/2020/03/01/compliance-matters-how-to-apply-the-new-cq-modifier 

UHC - APTA continues to dialogue with UHC on outstanding issues. The next meeting is scheduled for 9/16/22.

1. On the coding edits for 97530 and 97140 for the commercial plans, UHC is holding firm on its position. APTA will continue the advocacy effort.  

Per UHC: “After reviewing your input with our business partners, it was confirmed that the CCI edit was termed by CMS between 97530 and 97140, but the CMS Processing Manual and CPT Assistant still support a bundling edit.  Please note, a modifier override is allowed for this code pair when a separate and distinct service is provided.”

2. UHC is requesting providers forward the following redacted claims to APTA for sharing with the payer:

Per UHC: If you are seeing denials on these code pairs for the MA or retirement plans and UHCCP plans please provide claims examples to show what denials are occurring so UHC can research to determine if there is an issue.

April 12, 2022

• United Health Care - Community Plan: This UHCCP policy was just released in March…many potential issues.  Outpatient Physical and Occupational Therapy – Community Plan Coverage Determination Guideline (uhcprovider.com)

ACTION: APTA is working with the UHC medical director listing the problematic polices and provisions, highlighting the lack of direct access/ increased burden and asking for a call to discuss prior to the next quarterly meeting. 

This Coverage Determination Guideline only applies to the states of Arizona, California, Hawaii, Kansas, Maryland, Michigan, New York, Ohio, Rhode Island, Virginia, Washington, and Wisconsin.

(NOTE: other policies are state specific for IN, FL, NE, NC, KY, NJ)

• ·         Treatment: Treatment must be ordered by a physician and be Medically Necessary for the member’s plan of care POC.
• ·         Plan of Care: The initial authorization for therapy must also include a plan of care (POC). The POC must be signed and dated by the referring provider (PCP) (MD, DO, PA or NP) or appropriate specialist.
• ·         Group Therapy Documentation Requirements: The documentation must include all of the following: Prescribing provider’s order for Group Therapy Individualized treatment plan that includes frequency and duration of the prescribed Group Therapy and individualized treatment goals
• ·         Requests for Continuation of Therapy Visits Progress Reports (Summary of Progress): Signature and date of prescribing physician
• ·         Re-evaluations: A signed and dated physician order, less than 45 days old, is needed prior to the completion of a Physical Therapy or Occupational Therapy re-evaluation.
• ·         Treatment Session Notes: All treatment session notes must include: Date of treatment Specific treatment(s) provided that match the CPT code(s) billed Start and stop time in treatment corresponding to each CPT code billed.

• eviCore FAQ and Resources updated: These apply to all eviCore products/ contracts. The updated FAQ is posted here on the eviCore website:  Clinical Guidelines | Evidence-Based Medicine | eviCore.  

The following has been adapted from APTA Friday Focus: 

·         APTA, 95 Other Organizations to Congress: The Fee Schedule Just Isn't Working

A recent letter to committee leadership says that it's time for systemic change to the PFS and Quality Payment Program, which includes MIPS. 

·         Spending Package: A Win for Telehealth, No Movement on PTA Differential

The $1.5 trillion plan passed with bipartisan support. Here are three takeaways of interest to the physical therapy community. 

• Feds Recoup Relief Money From Providers Who Didn't Follow Reporting Rules

Some providers who received phase 1 CARES Act funds are being told to return the money. Phase 2 recipients can still set things right.

State Payer Advocacy Resource Center- SPARC

·        Great resource for your UM, payer questions and advocacy efforts:

March 1, 2022

 Access SPARC Here!

February 14, 2022

• POS 10 = Patient is receiving telehealth services while in their home
• POS 02 = Patient is receiving telehealth services outside of their home

• Blue Cross & Blue Shield of Rhode Island (BCBSRI) is offering a dual special needs plan, or D-SNP, to eligible Rhode Islanders.
• Training and attestation of completion is required for all in-network providers by March 30th, 2022.

• Medicare, Railroad Medicare, Humana prime and Tricare for Life

• CMS CQ Modifier Application and examples and overview found here: cms.gov/medicare examples using PTA CQ modifiers
• Current RI Practice Act Regulation Section 13.4.7 Supervision:

• A delay in the application of the payment differential and exempting those therapy assistants who are working in rural and medically underserved areas.

• State law to determine PTA supervision requirements for Medicare in outpatient therapy settings.

January 31, 2022

• A delay in the application of the payment differential and exempting those therapy assistants who are working in rural and medically underserved areas. 

• State law to determine PTA supervision requirements for Medicare in outpatient therapy settings.

December 20, 2021

• Provides a 3% payment increase to the 2022 Medicare Physician Fee Schedule resulting less of a total cuts from 4% to about 1% depending on the care provided and billing patterns
• The return of the 2% Medicare sequestration will be on hold until April 1 2022.
• Despite a strong and vocal coalition of advocates, the payment differential for therapy assistants still stands.
• Starting on January 1, the 15% payment differential will be imposed

• A delay in the application of the payment differential and exempting those therapy assistants who are working in rural and medically underserved areas.
• State law to determine PTA supervision requirements for Medicare in outpatient therapy settings.

• Cohere Health, a new entry to the UM landscape, is assuming responsibility for prior authorization for Humana in all 50 states effective 1/1/22.
• APTA has created a resource to help Providers and Practice Managers navigate these changes in the New Year.  
  
  • Submitting Therapy Guide (PT, OT, ST): This guide will walk you through the entire process of submitting a therapy authorization within the Cohere platform
  • Patient Reported Outcome Measures Toolkit: Collection of documents designed to assist providers in easy navigation of PROM tools per applicable body site
  • Therapy FAQs: Cohere's pre-existing collection of FAQs related to therapy services / authorizations
  • Therapy Webinar Slides & Recording: This webinar recording can be accessed any time and is designed to help answer your questions related to submitting therapy authorizations

Additional links on the Cohere program:

• Cohere Health’s Provider Knowledge Center includes training materials, webinars, and other onboarding resources
• Recent Provider Newsletter which includes the 50-state expansion announcement

  ---

May 24, 2021

• Tufts adopted NCCI Edits 
• When modifier 59 is applied, code reimbursement is reduced by 50%.

• Updated Policy as if 4/19 for OP PT: 
• RI APTA working for you: Decreased admin burden and removal of capped visits at 24
• Payment Committee continues to work with NHP to gain further clarification of documentation requirements. 
• Click here for Policy Update  Visit NHP website for full Policy

• Posts updated Early Intervention Services Mandate 5-2021

• Please see Policy and Version Compare feature on your Landscape for more details.

2/17/21

Payor Policy/Coverage Updates

CMS ~3.6% Payment Cut: Review of estimated 3.6% reduction in the final fee schedule. Click here for more details: apta/2021/01/06/conversion-factor-adjustment

• CIGNA: Cigna posts Policy Updates December 2020  Cigna Policy Update. Effective 3/15/2021 non-coverage of infrared and vaspneumatic. - (Alicemae Bell, PT, DPT) Effective March 15, 2021: Policies updated to note the application of infrared and vasopneumatic device is considered not medically necessary. CPT codes 97016 and 97026.  Physical Therapy – (CPG 135)
• Anthem: New limitations and exclusions: In December 2020, AIM issued new clinical guidelines AIM identified a list of excluded codes noted below. AIM Clinical Guidelines; https://aimspecialtyhealth.com/wp- content/uploads/2020/05/AIM_Guidelines_Rehab_OT-PT-ST.pdf (see pages 27 to 33).  APTA is in the process of challenging these guidelines restricting coverage of the following:

97014 Estim, unattended                       97012 Mechanical traction                   96004 Gait analysis, instrumented

96004 Motion analysis, instrumented      97033 Iontophoresis                    97016 Vasopneumatic compression

• Humana: Electrical Stimulators for Pain and Nausea/Vomiting 1-22-2021 Electrical Stimulators for Pain and Nausea/Vomiting

Utilization Management

• UnitedHealthcare is transitioning to InterQual criteria for all benefit plans effective May 1, 2021. InterQual criteria are nationally recognized, evidence-based clinical criteria that we’ll use for utilization management for all our benefit plans.  February 1, 2021 Announcement  *APTA is working on obtaining the guidelines for review. As providers, you may receive additional information/intel before the transition. If so, please share what you can with us. Contact: Elise Latawiec at eliselatawiec@apta.org*

• Medicare Advantage and Medicaid: If you’re a physical therapy provider facing challenges or delays in obtaining authorization to evaluate or treat your Medicare Advantage and Medicaid patients, we encourage you, and your patients, to contact 1-800-Medicare. Afterwards, contact advocacy@apta.org to alert us to your complaint and tracking number — you’ll help our advocacy efforts with payers and oversight entities, including CMS. 

Dealing With a Problematic Medicare Advantage and/or Medicaid Utilization Management Program? Contact Medicare — and Then Email APTA

• APTA General Template Letter: The attached template letter has been developed for providers to share with patients when utilization management policies are interfering with access to reasonable and necessary care. Patients may use this letter to reach out to their employer or human resource manager regarding the challenges.  Patient Letter to Employers re Access to PT Services

Update to CMS Payment Calculations Further Eases Impact of Cut

PHE Practice Expense Code 99702

Reminders:

• NHP Policy Update for PT, OT 2021

NCCI Edit information - 

NCCI Edit Updates: 

National Correct Coding Initiative: Commercial Payor Summary of Adoption of recent CMS NCCI Edit deletion:

• Humana will adopt new CMS NCCI edit files and apply retroactive to 1/1/20.  They will not automatically reprocess claims but will re process if claims are resubmitted.
• CIGNA will not retroactively process claims but will acknowledge the NCCI edits deletions starting 1/1/2021.
• Aetna will retroactively reprocess claims to 1/1/2020. However, providers DO NOTneed to resubmit their claims. Aetna will auto-process the claims. Aetna has indicated this could take several month.
• Humana will retroactively reprocess claims to 1/1/2020. However, providers DO need to resubmit their claims.

Currently, we're waiting for clarification from Anthem regarding their response to APTA.

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.

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. https://www.apta.org/article/2020/12/02/final-2021-pfs
• The MIPS portion of the rule will be published in the coming days

In Case you Missed it: On Friday, October 2, HHS Secretary Azar announced he is extending the public health emergency declaration, effective October 23, 2020 for the 3^rd time. 

The PHE will be up for renewal again January 23^rd (every 90 days).

This renewal, means that PTs and PTAs in private practice and facility-based physical therapy providers will:

• continue to have access to the temporary Medicare regulatory waivers, and
• new rules that afford providers flexibility to respond to COVID-19 pandemic, including telehealth coverage.

NCCI Edits Reinstated Oct. 1st: Strong effort by APTA

• APTA has been engaged with several insurances (Cigna, Aetna, Humana, BX) to eliminate claims being denied or flagged for use of the 59 modifier.  
• APTA has submitted requests to CMS for permanent elimination
• Ongoing education on use of the edits and supporting documentation requirements on the APTA website.
• We encourage providers who do experience high appeal overturn rates to contact the payer and/or APTA to see if the provider can get exempted from this policy.

Summary of common Therapy Codes affected: https://ppsapta.org/sl_files/ED27B611-A00A-A32C-23D0678E332A6EE9.pdf

Click here for Local and National Telehealth Guidelines 

(updated 2/17/21)
What you need to know on billing and providing telehealth

RI BCBS

• Update – No Cost share for hospital outpatient physical therapy when patient has a dx of COVID19.   

Telemedicine/Telephone Services: Updated Telemedicine Policy making Telehealth Permanent.  Effective 1/1/21

(As a result, BCBSRI’s Temporary Telemedicine/Telehealth and Telephone Services During the COVID-19 Crisis – Effective 3/18/20 policy will no longer be in effect for dates of service on or after 1/1/2021)

For updated Telemedicine Policy information click HERE: Telemedicine/Telephone Services for Commercial Products - Effective 1/1/2021

At a glance:

• BCBSRI will continue to reimburse telemedicine encounters at 100% of the in-office allowable as outlined in their policy per plan.
• Will cover Synchronous 2 way audiovisual telemedicine for Physical Therapy Services – NOT Phone. 
• Audio and Video telemedicine will require: POS02 and Modifiers 95  
• Lose cost share waivers
• Current CPT codes listed include most standard PT CPT codes.    
• RIAPTA working for you – Upon review of covered codes, CPT 97530, Therapeutic Activities, was omitted.  RI Blue Cross was contacted and reports this was in error.  CPT 97530 will be included on list of TH covered services. 

Blue Cross & Blue Shield of Rhode Island (BCBSRI) has extended its  Temporary Telemedicine/Telehealth and Telephone Services During the COVID-19 Crisis policy until December 31, 2020.

BCBSRI is taking this step in an effort to ensure members have access to the healthcare services they need virtually, as well as providing certainty to network providers that they will be able to continue to provide telemedicine services until the end of the year. Full details of the policy are available for review here.   

BCBS Telemedicine MODIFIER Updates:

As of 10/1/2020 For claims filed on or after October 1^st BCBSRI will require the following modifiers to be appended:

• Audio and Video telemedicine will require: POS02 and Modifiers 95 + CR , 95 in the first position and CR in the second.   
• Telephone only requires: POS02 Modifier CR  

Local and National Insurers extend coverage benefits for Telemedicine services:

BCBS of RI, Cigna, Aetna, Humana, Anthem – Extended to December 31^st

• BCBS of RI updated Telehealth Policy: BCBSRI Temp. Telemedicine Services COVID-19 Crisis policy 
• United Health: On Oct.1^st , extended to Dec. 31^st, 2020, BUT ends cost sharing for telehealth AND in clinic services as of October 1^st

Click here for all details: United Health COVID Update

See updated Telemedicine Reference Guide above.

NHP of Rhode Island– Adopts Medicare’s PTA, OTA CQ, CO modifiers

Medicaid, Integrity and Commercial now required for PTA’s and OTA’s respectively

Click here for updated policy information: nhpri.org/2020/Outpatient-PT OT Rehabilitation-Services10.01.20.pdf

NCCI Edits Reinstated Oct. 1st: Is your practice ready?

Effective October 1, CMS reversed and reinstated previously deleted coding "edits"  for code pairs that represent common and appropriate physical therapy practice.

A strong advocacy effort by APTA members and others helped to convince CMS to reverse that decision in April. Now CMS has moving ahead, providing no opportunities for input on its decision to reinstate.

Click here for APTA news article: APTA NCCI Coding Edits

PPS Summary of common Therapy Codes affected: https://ppsapta.org/sl_files/ED27B611-A00A-A32C-23D0678E332A6EE9.pdf

Click here for CMS NCCI Edit detail: CMS NCCI-Coding-Edits

What is new with the PHE Practice Expense Code 99702?

What’s this Code again? This new AMA code is for reporting expenses incurred as a result of the necessary public health response to a Public Health Emergency, in this case the COVID-19 Pandemic.

According to November 4^th APTA News Article:

• CMS : The Good/Bad News - CMS has added it to its physician fee schedule, BUT it was given a “B” status (CMS "B" Status) therefore is not reimbursable by CMS. We can bill to CMS but will not be reimbursed. 
• According to Kara Gainer, JD, Director of Regulatory Affairs for the APTA, ..”the commercial payment landscape is varied: some payers had already adopted this approach, others were waiting to see where Medicare landed, while still others are in fact paying on the code”
• We are staying on top of specific payor policy for this code.  Stay tuned!

For full November 4^th Article: Click Here: Apta.org/news November 4th CMS coding-decision-99072

For a more detailed review of code utility, click here for Sept. APTA article : https://www.apta.org/news/2020/09/25/new-cpt-code-covid

Documentation:

APTA Recorded Webinar: Skilled Physical Therapy Documentation Rules and Best Practices – 45 min http://communities.apta.org/p/do/sd/sid=6995

• Overview: APTA staff review Medicare’s physical therapy documentation requirements and discuss documentation best practices. They discuss how to overcome the documentation concerns reported by payers and review some of the standardized tests that assist physical therapists in quantifying documentation and goals. Finally, APTA staff review the differences between restorative and maintenance therapy and how to ensure your documentation reflects the medical necessity of both.
• Content included: 1. Recorded webinar: available on the Learning Center: https://learningcenter.apta.org/student/mycourse.aspx?id=ef73cf5d-222c-461f-9cf9-9770cb12ea12  2. Power point of the presentation 3. One sheet hand out: "Defending the documentation"