Zachary Edgar JD, LLM

Zachary Edgar JD, LLM

2019 Changes Annual Update Assistants Functional Reporting KX Modifier Manual Review NCCI Edits Merit-Based Incentive Payment System (MIPS)

Annual Update The 2019 Annual Update has not been added to Medicare s site CMS updated the Physician Self-Referral List of CPT/HCPCS Codes, and there are two deletions relevant to rehab therapy: 64550: Appl surface neurostimulator 96111: Developmental testing

Assistants Beginning January 1, 2022, payment for services provided in whole or in part by a therapy assistant will be reduced to 85% of the Part B payment. This applies to outpatient therapy services and providers that submit institutional claims for therapy services such as outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities (CORFs). The reduced payment rate is not applicable to outpatient therapy services furnished by critical access hospitals. New PTA and OTA modifiers must be used beginning January 1, 2020.

Modifiers for Therapist Services Revised GP modifier: Services fully furnished by a physical therapist or by or incident to the services of another qualified clinician that is, physician, nurse practitioner, certified clinical nurse specialist, or physician assistant under an outpatient physical therapy plan of care. Revised GO modifier: Services fully furnished by an occupational therapist or by or incident to the services of another qualified clinician that is, physician, nurse practitioner, certified clinical nurse specialist, or physician assistant under an outpatient occupational therapy plan of care.

Modifiers for Therapy Assistants PTA Modifier CQ: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant. OTA Modifier CO: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.

Therapists and Assistants CMS has finalized 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. We 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 rulemaking for CY 2020.

Functional Reporting Modifications Discontinued as of January 1, 2019 The Functional Reporting requirements of reporting the functional limitation nonpayable HCPCS G-codes and severity modifiers on claims for therapy services and the associated documentation requirements in medical records have been discontinued, effective for dates of service on and after January 1, 2019.

Therapy KX Threshold Amounts Increase the CY 2018 KX modifier threshold amount of $2,010 by the CY 2019 MEI of 1.5 percent and rounding to the nearest $10.00 results in a CY 2019 KX threshold amount of $2,040 for PT and SLP services combined and $2,040 for OT services.

The Targeted Medical Review Process CY 2019, the MR threshold is $3,000 for PT and SLP services combined and $3,000 for OT services. Under the established targeted review process, some, but not all claims exceeding the MR threshold amount are subject to review. CMS targets therapists that have a higher percentage of patients that exceed the threshold compared with the utilization average.

NCCI Edits Practitioner Services MUE Table Effective 01-01-2019 [ZIP, 350KB] Quarterly Additions, Deletions, and Revisions to Published MUEs for Practitioner Services Effective January 1, 2019 [ZIP, 17KB] Practitioner PTP Edits v25.0 effective January 1, 2019 (529,244 records) 38100/0213T 61888/G0471

CPT codes 97760 (Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes) and 97761 (Prosthetic(s) training, upper and/or lower extremity(ies), initial prosthetic(s) encounter, each 15 minutes) are not separately reportable for the same date of service with physical therapy re-evaluation CPT code 97164 or occupational therapy re-evaluation CPT code 97168 when the two services are performed by a single practitioner or two practitioners of the same specialty. If the two services are performed by two different practitioners of different specialties, the two services may be reported utilizing an NCCI-associated modifier.

Merit-Based Incentive Payment Program MIPS combines three legacy programs Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals, Physician Quality Reporting System, and the Value-Based Payment Modifier

MIPS Eligibility Criteria Physician Physician assistant Nurse practitioner Clinical nurse specialist Certified registered nurse anesthetist Physical therapist Occupational therapist Qualified speech-language pathologist Qualified audiologist Clinical psychologist Registered dietitian or nutrition professionals

Low-Volume Threshold Criteria Bill more than $90,000 a year in allowed charges for covered professional services under the Medicare Physician Fee Schedule (PFS) And Furnish covered professional services to more than 200 Medicare beneficiaries a year And Provide more than 200 covered professional services under the PFS

Excluded You re also excluded from MIPS in the 2019 performance year if you: Enrolled in Medicare for the first time in 2018 Or Participate in an Advanced APM and are determined to be a Qualifying APM Participant (QP) Or Participate in an Advanced APM and are determined to be a Partial QP and do not elect to participate in MIPS

Adjustment January 1, 2021 MIPS payment adjustments are prospectively applied to each claim beginning January 1, 2021 The maximum negative payment adjustment is -7%. A positive payment adjustment generally can be up to 7% (but they the upward payment adjustment factor is multiplied by a scaling factor to achieve budget neutrality, which could result in an adjustment above or below 7%).

Categories Quality: 45% Promoting Interoperability: 25% Cost: 15% Improvement Activities: 15%

Quality Measures Must report on 6 measures One of these measures should be an outcome measure; if you have no applicable outcome measure, you can submit a high priority measure instead Claims: 60% of Medicare Part B patients for the performance period. QCDR/Registry/EHR: 60% of clinician's or group's patients across all payers for the performance period. CMS Web Interface: Sampling requirements for Medicare Part B patients. CAHPS for MIPS Survey: Sampling requirements for Medicare part B patients.

Quality Measure Example Functional Outcome Assessment # 182 Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.

Improvement Activities Score: 15% More than 15 Clinicians: To earn full credit in this category, participants must submit one of the following combinations of activities (each activity must be performed for 90 days or more during 2019): 2 high-weighted activities 1 high-weighted activity and 2 medium-weighted activities At least 4 medium-weighted activities

Examples Collection and follow-up on patient experience and satisfaction data on beneficiary engagement Completion of an Accredited Safety or Quality Improvement Program Engagement of community for health status improvement

Useful Links https://qpp.cms.gov/participation-lookup https://therapycomply.com/merit-based-incentive-payment-system- (MIPS)

Upcoming Webinars Texas Telehealth for Physical and Occupational Therapist on January 30th at 12:00-1:00 PM CDT Medicare Documentation and Appeals for Physical and Occupational Therapists - February 6th at 12:00-1:00 PM CDT Merit-Based Incentive Payment Systems (MIPS) for Physical and Occupational Therapists - February 13th at 12:00-1:00 PM CDT

zedgar@med-comply.com www.therapycomply.com