Don’t Discount Your Value

Janet Shelley
By Janet Shelley, PT, DPT, Chairperson

2018 began with a change in the value of many Current Procedural Terminology (CPT) codes used by physical therapists to bill the Medicare program for their services. Some increased, others diminished, but overall, the value assigned to physical therapy services by both federal and commercial payers continues to threaten the viability of the private practitioner.

The Payment Policy Committee is focused on providing Private Practice Section (PPS) members with tools and resources to help you demonstrate the value of physical therapy, sharpen your skills to navigate the contracting world, and to evaluate alternative payment methodologies such as cashbased services, out-of-network status, and bundled payment models. We want PPS members to recognize their value, promote it to payers, and enrich their payer contracts based on that value. “Don’t Discount Your Value” has become our committee motto.

Our 2018–2019 work groups are organized around current private practice experiences: The Emerging Issues Task Force is designed to help members stay abreast of regulations and developments that impact our daily practice. This group is working to promote inclusion of physical therapists as eligible providers via telehealth. They are following the development of new procedural codes regarding dry needling and closely monitoring the anticipated changes to the Merit-Based Incentive Payment System (MIPS). Are physical therapists going to be required to report under MIPS, a widely reported burdensome regulation (think Physician Quality Reporting System [PQRS] on steroids), and if so when?

More than 20 years ago, there was a provision in the Health Insurance Portability and Accountability Act (HIPAA) statute that was meant to reduce paperwork and streamline business processes across health care. Prior-authorization requirements, clinical submission forms, claim denials because each payer wants the info in different blocks on the “standard” claim form are just a few examples. The Administrative Simplification Task Force is working with other health care provider associations that are wrestling with these same regulations. Twenty years is long enough for enactment, the initial intent of HIPAA needs to be enforced!

The Value Driven Payment and Contracting Task Force is focused on facilitating the conversation about the worth of physical therapy. Evidence-based resources are being packaged so that an individual private practice can present a bank of data that proves the efficacy and savings associated with physical therapy when used early in an episode of care and before other expensive imaging procedures or surgery. We want consumers and insurers to think “physical therapy first” for most musculoskeletal conditions. This group produced a Model Contract Checklist last year to help our members understand key language provisions in their payer contracts. Look for a “toolkit” this fall that will show you how to use your practice’s key metrics and outcomes to negotiate payment based on examples of value-based physical therapy programs.

Our committee is also focused on ensuring that the members are practicing in compliance with payer policy and regulations. The Cash Based/Out of Network (OON) Task Force is working to help members answer questions such as “Can I take cash from a Medicare patient?” “If I am out of network with an insurer, can I waive the patient’s copay?” “Does filing the claim as a courtesy for my patient impose any additional responsibilities on an OON provider?” We hope our pursuit of these issues is valuable to your practice and welcome participation on any of the task forces.

Janet Shelley, PT, DPT, is the chair of the PPS Payment Policy Committee and chief executive officer of Medical Billing Center in Greenville, South Carolina, specializing in billing for outpatient therapy. She can be reached at

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