2021 Medicare Changes Impacting Physical Therapy Services
By Rick Gawenda*
On December 2, 2020, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2021 final rule for services paid under the Medicare Physician Fee Schedule (MPFS) as well as the Quality Payment Program, better known as the Merit-Based Incentive Payment System (MIPS).
On December 27, 2021, President Trump signed The Consolidated Appropriations Act, 2021 into law and this legislation had positive implications for outpatient therapy services. In this article, I will highlight aspects of the final rule and The Consolidated Appropriations Act, 2021 as they pertain to outpatient therapy services.
2021 MEDICARE PHYSICIAN FEE SCHEDULE CONVERSION FACTOR
In the final rule, CMS announced the MPFS conversion factor (CF) would be 32.4085.1 This is a 10.2% decrease compared to the 2020 MPFS CF of 36.0896. Due to increases in some of the relative value units of CPT codes billed by physical therapists, occupational therapists and speech-language pathologists, the overall decrease in payment for outpatient therapy services was estimated to be approximately 9% in CY 2021.
On December 21, 2020, The United States House of Representatives and United States Senate passed The Consolidated Appropriations Act, 2021 and this legislation was signed into law by President Trump on December 27, 2020. The legislation ordered the Secretary of Health and Human Services (HHS) to increase the MPFS by 3.75% for services furnished on and after January 1, 2021 through December 31, 2021.2
In addition, the legislation placed a moratorium on the payment for G2211 from January 1, 2021 through December 31, 2023.2 G2211 is a new Medicare-specific add-on code to report office/outpatient E/M visit complexity.
G2211 – “Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established”2
The Centers for Medicare and Medicaid Services (CMS) had estimated that G2211 would account for approximately 3% of total payments under the MPFS in calendar year 2021. Since CMS is unable to pay for G2211 through December 31, 2023, CMS does have the authority to add this approximate 3% savings back into the 2021 Conversion Factor.
Finally, on January 5, 2021, CMS released the final 2021 MPFS CF. The revised 2021 CF for services paid under the MPFS is 34.8931.3 This is approximately a 3.33% decrease from the 2020 CF of 36.0896 (rounded to 36.09).
2021 CPT CODE PAYMENTS COMPARED TO 2020
For services paid under the MPFS, there are 112 payment localities. This means what the Medicare allowed amount is for 1 CPT code in one payment locality will be different for the same CPT code in another payment locality. With the 2021 CF decreasing by 3.33% compared to the 2020 CF, how will this decrease impact payment for services provided by physical therapists? For my example below, I used Detroit, Michigan as the payment locality.
SUPERVISION REQUIREMENTS OF A PHYSICAL THERAPIST ASSISTANT
Under normal circumstances, CMS requires the physical therapist provide direct supervision to the physical therapist assistant when they are treating a Medicare beneficiary for outpatient therapy services in a private practice setting. Due to the public health emergency due to COVID-19, CMS has eased the direct supervision requirements of a PTA or an OTA in the private practice setting. During the public health emergency, CMS is revising the definition of direct supervision to include a virtual presence through the use of interactive telecommunications technology for services paid under the MPFS.
The news got even better on December 2, 2020 when CMS released the CY 2021 final rule for services paid under the MPFS. In the final rule, CMS finalized their proposal to allow direct supervision to be provided using real-time, interactive audio and video technology (excluding telephone that does not also include video) through the later of the end of the CY in which the public health emergency ends December 31, 2021.1 For example, if the public health emergency ends April 20, 2021, this revised direct supervision requirement would end December 31, 2021. However, if the public health emergency did not end until January 20, 2022, this revised direct supervision requirement would end December 31, 2022.
The requirement could be met by the supervising physical therapist being immediately available to engage via audio/video technology (excluding audio-only) and would not require real-time presence or observation of the service via interactive audio and video technology throughout the performance of the procedure. If your state practice act requires direct supervision of the PTA by the physical therapist and this requirement has not been eased, then you must adhere to the policy that is most restrictive or stringent. In this example, this means you would need to adhere to your state practice act.
2021 ANNUAL THERAPY THRESHOLD AND TARGETED MEDICAL REVIEW THRESHOLD
In the final rule, CMS did not publish the 2021 therapy threshold dollar amount for outpatient therapy services. On December 3, 2020, CMS re-communicated Transmittal 10464 and announced the 2021 therapy threshold dollar amount would be $2,110 for physical therapy and speech therapy combined and a separate $2,110 for occupational therapy. The targeted medical review threshold remains at $3,000 for physical therapy and speech therapy combined and a separate $3,000 for occupational therapy in CY 2021.4
EXTENSION OF THE WORK GEOGRAPHIC INDEX FLOOR MINIMUM OF 1.0
The Consolidated Appropriations Act, 2021 extends the Work Geographic Index Floor minimum of 1.0 until January 1, 2024.2 This means that all localities that had a Work Geographic Index of less than 1.0 will be increased to 1.0. This index does impact your payment for each CPT code. The higher the index, the better. If your 2021 Work Geographic Index Floor was already 1.0 or greater, you will keep the higher value and will not be reduced to the 1.0 minimum.
STUDENT DOCUMENTATION IN THE MEDICAL RECORD
CMS clarified that therapy students can document in the medical record so long as it is reviewed and verified (signed and dated) by the billing therapist. CMS is also clarifying that the broad policy principle that allows billing clinicians to review and verify documentation added to the medical record for their services by other members of the medical team also applies to therapists.1
During a CMS Office Hours call on December 22, 2020, CMS did confirm that a PTA could co-sign a note written by a PTA student and that the supervising physical therapist would also not need to co-sign the note from a CMS perspective.5 If your state practice act requires notes written by a PTA be co-signed by the supervising physical therapist, then you must adhere to your state practice act since it’s more stringent than CMS.
MAINTENANCE THERAPY PROVIDED BY PTAS AND OTAS
CMS finalized their proposal to make permanent their Part B policy for maintenance therapy services that CMS adopted on an interim basis for the PHE in the May 8th COVID-19 IFC that grants a physical therapist and occupational therapist the discretion to delegate the performance of maintenance therapy services, as clinically appropriate to a PTA or an occupational therapy assistant (OTA). This will align CMS Part B policy with that paid under Part A in skilled nursing facilities and the home health benefit where maintenance therapy services may be performed by a physical or occupational therapist or a PTA/OTA.1
COMMUNICATION TECHNOLOGY-BASED SERVICES (CTBS)
CMS finalized their proposal to allow NPPs, such as licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and SLPs to bill HCPCS codes G2061 through G2063, consistent with the definition of their respective benefit category.
CMS also finalized their proposal to replace G2061 – G2063 with CPT codes 98970 – 98972. This means G2061 will now become 98970, G2062 will now become 98971 and G2063 will now become 98973 beginning on January 1, 2021.
In addition, CMS will allow physical therapists, occupational therapists and speech-language pathologists to bill the following two Level II HCPCS codes:
G2250: Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous seven days nor leading to a service or procedure within the next 24 hours or soonest available appointment.
G2251: Brief communication technology-based service, e.g., virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous seven days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
CMS did finalize their proposal to designate these CTBS codes as “sometimes therapy” services when billed by a private practice physical therapist, occupational therapist or speech-language pathologist. Additionally, when these codes are billed by a private practice physical therapist, occupational therapist, or SLP, the codes would need to include the corresponding GO, GP, or GN therapy modifier to signify that the CTBS was furnished as therapy services furnished under an occupational therapist, physical therapist, or SLP plan of care.1
TELEHEALTH UNDER MEDICARE IN 2021
During the duration of the PHE (scheduled to end on April 20, 2021 at the time of the writing of this article), CMS is reimbursing for outpatient physical, occupational and speech therapy services delivered via telehealth. Once the PHE is declared over, CMS will not reimburse for outpatient therapy services delivered via telehealth by physical therapists or physical therapist assistants in private practice or a facility setting.
In the final rule, CMS did finalize their proposal to have the following CPT codes remain temporarily on the Medicare telehealth list through the end of the year in which the PHE for COVID-19 ends (category 3 services):
92521- 92524, 92507, 97161 – 97168, 97110, 97112, 97116, 97535, 97750, 97755, 97760, and 97761.
Unfortunately, CMS does not have the authority to add physical therapists, occupational therapists or speech-language pathologists as authorized practitioners who may independently bill Medicare for telehealth services. However, the above services may be billed if provided by a physician or non-physician practitioner, where allowed by state law, or if provided by a physical therapist, occupational therapist or speech-language pathologist incident-to a physician (i.e., physician owned practice).
MIPS IN 2021
Highlights of the 2021 MIPS program as it applies to physical therapists in private practice include the following:
Performance threshold is 60 points to avoid a negative payment adjustment in 2023.
Physical therapists can participate in MIPS as an individual, as a group or as a virtual group.
Quality Performance category will account for 85% of your final score while the Improvement Activities category will account for 15% of your final score.
CMS added Measures 283 and 286 to the physical therapy and occupational therapy specialty set and deleted Measure 282 from the physical therapy and occupational therapy specialty set.
CMS added physical therapy MIPS eligible clinicians to the denominator eligible encounters to Measure 226 (Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention) for both claims and registry reporting.
Low-volume threshold remains the same for Performance Year (PY) 2021 as it was in PY 2020 and PY 2019.
1Centers for Medicare & Medicaid Services. 42 CFR Parts 400, 410, 414, 415, 423, 424, and 425 [CMS-1734-F, CMS-1734-IFC, CMS-1744-F, CMS-5531-F and CMS-3401-IFC] RIN 0938-AU10, 0938-AU31, 0938-AU32, and 0938-AU33, Medicare Program; CY 2021 Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; Medicaid Promoting Interoperability Program Requirements for Eligible Professionals; Quality Payment Program; Coverage of Opioid Use Disorder Services Furnished by Opioid Treatment Programs; Medicare Enrollment of Opioid Treatment Programs; Electronic Prescribing for Controlled Substances for a Covered Part D Drug; Payment for Office/Outpatient Evaluation and Management Services; Hospital IQR Program; Establish New Code Categories; Medicare Diabetes Prevention Program (MDPP) Expanded Model Emergency Policy; Coding and Payment for Virtual Check-in Services Interim Final Rule Policy; Coding and Payment for Personal Protective Equipment (PPE) Interim Final Rule Policy; Regulatory Revisions in Response to the Public Health Emergency (PHE) for COVID-19; and Finalization of Certain Provisions from the March 31st, May 8th, and September 2nd Interim Final Rules in Response to the PHE for COVID-19. https://www.govinfo.gov/content/pkg/FR-2020-12-28/pdf/2020-26815.pdf. Accessed January 12, 2021.
2Consolidated Appropriations Act, 2021. https://www.congress.gov/116/bills/hr133/BILLS-116hr133enr.pdf. Accessed January 12, 2021
3Centers for Medicare and Medicaid Services. Medicare, Physician Fee Schedule, PFS Relative Value Files, 2021, RVU21A. https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-relative-value-files/2021. Accessed January 12, 2021.
4Centers for Medicare and Medicaid Services. Transmittal 10464, Change Request 12014. https://www.cms.gov/files/document/r10464CP.pdf. Published November 13, 2020. Accessed January 12, 2021.
5Centers for Medicare and Medicaid Services. Outreach & Education, Partner Resources, Open Door Forums, Podcast and Transcripts. https://www.cms.gov/Outreach-and-Education/Outreach/OpenDoorForums/PodcastAndTranscripts.
Published December 8, 2020. Accessed January 7, 2021.
Rick Gawenda, PT, is the founder and president of Gawenda Seminars & Consulting, Inc. and member of the PPS Payment Policy Committee. He may be reached at firstname.lastname@example.org and on Twitter @gawendaseminars.
*The author has a professional affiliation with this subject.