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CMS New Physician Fee Schedule is Out and We NEED your help in advocating against this proposal!
2019-08-21

As you may know, on July 29, 2019, the Centers for Medicare and Medicaid Services (CMS) released the 2020 Medicare Physician Fee Schedule (PFS) proposed rule. Within this rule, CMS puts forth additional guidance regarding application of the new therapy assistant modifiers (CQ/CO modifiers for outpatient therapy services furnished by PTA or OTAs respectively). This builds upon CMS’s guidance issued in last year’s PFS final rule.

As background – Under the Bipartisan Budget Act of 2018 Section 53107, beginning on January 1, 2020, outpatient therapy providers are required to use a modifier to denote when outpatient therapy services are furnished in whole or in part by a PTA or OTA. In 2022, payment for outpatient therapy services furnished in whole or in part by a PTA or OTA will be reimbursed at 85% of the fee schedule. The reduced payment rate is applicable when payment is made under the fee schedule for outpatient therapy services furnished in private practice, outpatient hospitals, rehab agencies, SNFs, HHAs, and CORFs. In the 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 January 1, 2020, on the claim line of the service alongside the respective GP or GO therapy modifier to identify services furnished under a physical therapy or occupational therapy plan of care. CMS also 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. CMS also noted they would be putting forth more guidance in the 2020 PFS rule. 

Now that the 2020 PFS proposed rule has been released and APTA has had a chance to review the proposed policy, APTA (and AOTA and other stakeholders) have serious concerns. In APTA’s view, the modifier policy proposed in this rule is not only inherently complex, but it is a gross overreach of CMS’s statutory authority, is not in line with congressional intent, and would result in drastic underpayments for outpatient therapy services beginning in 2022, severely restricting beneficiary access to vital therapy services, particularly in rural and underserved areas. The policy fails to put the needs of the patient first and ignores the therapist’s active engagement in treatment, reducing reimbursement not only for the assistant’s services but also the services performed by the therapist. Moreover, if CMS adopts this flawed policy, not only will it negatively impact providers treating Medicare beneficiaries, but commercial payers are likely to adopt the same flawed policy, thereby negatively impacting all outpatient physical (and occupational) therapy providers.

APTA is pushing back against this proposal, including bringing this to the attention of their friends on the Hill. But APTA needs your help in advocating against CMS’s proposal! APTA is asking all PTs, PTAs, and students of physical therapy to submit comments to CMS, opposing the proposed application of the 10% de minimis standard, using APTA’s template letter. It only takes 5 minutes! The template letter for clinicians and the template letter for patients can be found on APTA’s Regulatory Issues: Take Action webpage. Copied below is where the template letters can be found on the webpage. The letters can be accessed and personalized by anyone – members and non-members.

  • CMS 2020 Physician Fee Schedule Proposed Rule: The Centers for Medicare and Medicaid Services (CMS) issued its proposed rule on the physician fee schedule and Quality Payment Program (QPP) for 2020. It outlines rules for applying modifiers when a PTA furnishes outpatient therapy services at least in part; sets reimbursement values for the new trigger point injection dry needling codes; and seeks feedback on opportunities to expand the concept of bundling to recognize efficiencies among services paid under the fee schedule. CMS also proposes revisions to QPP's MIPS program, including changes to the PT/OT measure set for 2020 and a new, simpler MIPS Value Pathways (MVPs) option starting in 2021 that would align activities across the 4 MIPS categories by specialties or conditions. APTA will provide comments, and individuals may submit comments independently using an APTA template letter developed specifically for the proposed rule (link below). 

    Deadline for Comments: Friday, September 27, 2019 Review proposed rule (.pdf) Review fact sheet Review press release

    Take Action: Submit comments | PTA Modifier Policy Template Letter for Clinicians (.docx) | Access to therapy services patient template letter (PTA modifier, SNF PDM, HHA PDGM, copays, prior authorization) (.docx)
Please note that although the comment deadline is not until September 27, it is critical that CMS receive a mass set of comments early, i.e., before Labor Day, in order to afford the agency adequate time to review the comments and make revisions to the policy.  

Please do not hesitate to contact Kara Gainer, APTA’s Director of Regulatory Affairs, at karagainer@apta.org should you have any questions.
 
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