2019 Updates for Physical Therapy Services

Calendar

By Rick Gawenda

On November 1, 2018, the Centers for Medicare and Medicaid Services (CMS) issued the 2019 final rule for services paid under the Medicare Physician Fee Schedule (outpatient PT, OT, and SLP services), as well as the Merit-Based Incentive Payment System (MIPS) for physical therapists, occupational therapists, and speech-language pathologists in private practice.

In this article, I will highlight some of the important updates and changes physical therapists in private practice need to be aware of for 2019.

2019 Conversion Factor

The conversion factor is a value used by the Centers for Medicare and Medicaid Services to turn relative value units into a dollar amount for each CPT code paid under the MPFS. The 2019 conversion factor will be $36.0391 compared to the 2018 conversion factor of $35.9996. This is a whopping 0.11 percent increase.1

2019 Therapy Threshold Dollar Amount

The therapy threshold dollar amount is adjusted annually by the percentage increase in the Medicare Economic Index (MEI) and is then rounded to the nearest $10.00. The 2019 MEI percentage increase is 1.5 percent. Take the 2018 therapy threshold dollar amount of $2010 and multiply it by 1.5 percent and this equals $30.15. Add the $30.15 to the $2010, and rounding to the nearest $10.00 gives you the 2019 therapy threshold dollar amount of $2,040 for physical therapy and speech therapy services combined and a separate $2,040 for occupational therapy.2

2019 Targeted Medical Review Dollar Amount

The 2019 targeted medical review dollar amount will remain at $3,000 for physical therapy and speech therapy services combined and a separate $3,000 for occupational therapy.3

Functional Limitation Reporting

CMS is finalizing their proposal to end functional limitation reporting (FLR) for traditional Medicare Part B therapy services effective for dates of service on and after January 1, 2019. This only applies to traditional Medicare Part B beneficiaries. If you have Medicare Advantage plans, other commercial insurance carriers, or workers compensation carriers requiring FLR, this does not apply to them and they may continue to require FLR in 2019.4

New Modifiers to Distinguish Services Provided by a PTA or OTA

CMS has established two new modifiers that will be appended to CPT codes on the claim form in addition to the therapy-specific modifiers (i.e., GO, GP) when the service(s) was provided in whole or in part by a physical therapist assistant (PTA) or an occupational therapist assistant (OTA). These new modifiers will be required beginning with dates of service on and after January 1, 2020.

The two modifiers are:

  • 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 occupational therapist assistant.5

How would this look on a claim form beginning in 2020? Examples: 97110GPCQ, 97530GOCO.

“In Whole or in Part” Defined of a PTA or OTA Service

CMS is finalizing a de minimis standard under which a service is furnished in whole or in part by a PTA or OTA when more than 10 percent of the service is furnished by the PTA or OTA. For example, if a Medicare beneficiary received 15 minutes of therapeutic exercise, 1.5 minutes could be furnished by the PTA or OTA without being subject to the discounted payment rate.

CMS did state in this final rule that they anticipate addressing application of the therapy assistant modifiers and the 10 percent standard more specifically, including their application for different scenarios and types of services, in rule making for calendar year (CY) 2020.5

2019 MIPS for Physical Therapists FAQs

How will I know if I will be required to participate in MIPS in 2019?

A MIPS-eligible clinician will be required to participate in MIPS in 2019 if they exceed all three of the low-volume thresholds during the determination period(s).5

In 2019, what are the three low-volume thresholds?

In 2019, if an eligible clinician exceeds all of the following three low-volume thresholds, they will be required to participate in MIPS in 2019:

  1. You have > $90,000 in Medicare Part B allowed charges
  2. You evaluated and/or treated > 200 unique Medicare beneficiaries
  3. You provided > 200 covered professional services under the Medicare Physician Fee Schedule 6

How is the $90,000 in Medicare Part B allowed charges calculated?

For purposes of the low-volume threshold, the Medicare Part B allowed charges is the Medicare allowed amount for each CPT code prior to the application of the multiple procedure payment reduction policy.7

How is the > 200 unique Medicare beneficiaries calculated?

For a physical therapist (PT) or occupational therapist (OT) in private practice, generally, your services are billed under your national provider identifier (NPI) number with payment reassigned to the practice. If you evaluate and/or treat > 200 unique (different) Medicare beneficiaries during the determination period(s), you will exceed this low-volume threshold. Keep in mind that services provided by a physical therapist assistant (PTA) or occupational therapist assistant (OTA) in a private practice are billed under the NPI of the PT or OT who is providing the direct supervision. This means that one PT could evaluate a Medicare beneficiary, and that would count as one unique Medicare beneficiary for that PT. That Medicare beneficiary now comes in for a follow-up visit and is seen by a PTA. The PT who did the evaluation is not on site that day, so the PTA is being directly supervised by a different PT. Since the services of the PTA are billed under the NPI of the PT who is providing the direct supervision, this Medicare beneficiary would now count as a unique Medicare beneficiary for the second PT as well since they are providing the direct supervision to the PTA.

How is the > 200 covered professional services under the Medicare Physician Fee Schedule?

Per the CMS final rule, “A clinician may identify and monitor a claim to distinguish covered professional services from Part B items and services by calculating one professional claim line with positive allowed charges to be considered one covered professional service.”8

For example, if a clinician billed CPT code 97110 (therapeutic exercise) on one claim line for 3 units, this would count as one covered professional service. However, if a clinician billed CPT code 97110 for 3 units but billed it as 1 unit on three different claim lines, this would count as three covered professional services.

What is the determination period that CMS will use to see if an eligible clinician will be required to participate in MIPS in 2019?

CMS will use two 12-month segments to determine if an eligible clinician will be required to participate in MIPS in 2019. The first segment begins October 1, 2017, and ends on September 30, 2018, and will include a 30-day claims run-out. The second segment will begin on October 1, 2018, and end on September 30, 2019, and would not include a claims run-out but would include quarterly snapshots for informational use only, if technically feasible.

If an eligible clinician exceeds all three low-volume thresholds at the same practice during both determination periods, they will be required to participate in MIPS in 2019.

If an eligible clinician exceeds all three low-volume thresholds during the first determination period, stays in the same practice and does not exceed all three low-volume thresholds during the second determination period, they will not be required to participate in MIPS in 2019.

If an eligible clinician does not exceed all three low-volume thresholds during the first determination period, leaves that practice and joins another private practice, if they exceed all three low-volume thresholds during the second determination period in their new private practice, they would be required to participate in MIPS in 2019.9

If I’m not required to participate in MIPS in 2019, can I opt-in for the chance for a positive payment adjustment in 2021?

Yes! A physical therapist in private practice can opt-in to the MIPS program for performance year 2019 as long as they, as an individual (single NPI), as a group (2 or more NPIs under one tax ID number), or as a virtual group, exceed at least one of the three low-volume thresholds during the determination period(s).10

In conclusion, it’s very important that private practice owners and physical therapists read the final rule to gain a complete understanding of the MIPS program since I’m unable to provide all the detailed information in this article. Be sure to check out all the American Physical Therapy Association resources on MIPS at www.apta.org/mips.


References:

1. Department of Health and Human Services, Centers for Medicare and Medicaid Services, Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; Medicaid Promoting Interoperability Program; Quality Payment Program—Extreme and Uncontrollable Circumstance Policy for the 2019 MIPS Payment Year; Provisions from the Medicare Shared Savings Program—Accountable Care Organizations—Pathways to Success; and Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, p. 1914. https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.

2. Department of Health and Human Services, Centers for Medicare and Medicaid Services, pp. 662-663.

3. Department of Health and Human Services, Centers for Medicare and Medicaid Services, p. 663.

4. Department of Health and Human Services, Centers for Medicare and Medicaid Services, pp. 657-661.

5. Department of Health and Human Services, Centers for Medicare and Medicaid Services, pp. 637-657.

6. Department of Health and Human Services, Centers for Medicare and Medicaid Services, pp. 919-929.

7. Department of Health and Human Services, Centers for Medicare and Medicaid Services, p. 928.

8. Department of Health and Human Services, Centers for Medicare and Medicaid Services, p. 917.

9. Department of Health and Human Services, Centers for Medicare and Medicaid Services, pp. 903-914.

10. Department of Health and Human Services, Centers for Medicare and Medicaid Services, pp. 929-947.

Rick Gawenda

Rick Gawenda is the president of Gawenda Seminars & Consulting and a member of the PPS Payment Policy Committee. He can be reached at info@gawendaseminars.com.