Cruel CMS Summer: The 2025 Proposed Rule is Here

Depending on your preferences, this summer’s hottest trend is either the fiery-hot passions of Taylor Swift fans as they descend on concert venues or the blistering temperatures that have lasted far longer than a fortnight. (We’ll let you decide depending on your personal preferences.) Not to be outdone, the Center for Medicare and Medicaid Services (CMS) has its own hot new release, a Tortured Poets Department (Tortured Physicians Department?) to turn people away from the summer heat and packed music venues and towards their laptops: the CY 2025 Medicare Physician Fee Schedule. 

Ok, that may be overstating it by a lot; even the biggest rehab therapy nerd would tell you that parsing the hundreds of pages in the proposed rule is far less fun than deciphering which songs are about which celebrity beau. But that shouldn’t stop us from digging into the latest volume of rule changes and updates to see what’s coming for rehab therapists when the final rule is released in late fall. (Beyond cooler temperatures, that is.) Fortunately, the usual dose of bad regarding reimbursements is tempered by some positive developments that should give PTs, OTs, and SLPs a bit more freedom in how they deliver services. So pull up a chair, get every fan you own going, and read up on the changes coming for 2025.   

The conversion factor is getting cut yet again. 

Let’s get the negative out of the way up front: yes, the conversion factor that determines how much you’re getting paid for services provided to Medicare patients is, at present, being reduced once more. The estimated 2025 PFS conversion factor is $32.36, dropping from $33.29 in CY 2024. The decrease is largely tied to the end of a temporary 2.93 percent increase that was put in place from March 2024 through the end of this year. As always, comments are open for the proposed rule, so if you’re unhappy with the cut—and why wouldn’t you be—make your displeasure known to CMS.     

The therapy threshold is inching up.

Fortunately, we can count on at least the KX modifier threshold to increase year over year. For CY 2025, the threshold amount is $2,410 for physical therapy and speech-language pathology services combined and $2,410 for occupational therapy services. Of course, we’re obliged to note as always that the $2,410 amount is merely a threshold, not a cap on services, so you don’t have to stop treating patients at that point—just that you need to affix the KX modifier to any subsequent services and document why additional treatment is medically necessary.     

While we’re mentioning the therapy threshold, we would be remiss not to mention the coming changes to the targeted medical review (MR).  At present and through the end of CY 2027, targeted MRs occur after a patient reaches the $3000 of billed services for its beneficiaries. Starting in CY 2028, the targeted MR will have a threshold that is updated annually based on the percentage increase in the Medicare Economic Index (MEI). But just because there is a targeted MR threshold does not mean everyone who goes over $3000 gets a review. Instead, CMS states they will use the following factors (see page 369) to determine whether a targeted MR will be rendered:

1. The therapy provider has had a high claims denial percentage for therapy services under this part or is less compliant with applicable requirements under this title. 
2. The therapy provider has a billing pattern for therapy services under this part that is aberrant compared to peers or otherwise has questionable billing practices for such services, such as billing medically unlikely units of services in a day. 
3. The therapy provider is newly enrolled under this title or has not previously furnished therapy services under this part. 
4. The services are furnished to treat a type of medical condition. 
5. The therapy provider is part of a group that includes another therapy provider identified using the factors described previously in this section. 

So keep these factors in mind when you are near the KX threshold mark, and remember that regardless of the diagnosis, POC, or other factors, the first line of defense for a targeted MR is defensible documentation.

The 19 misvalued RVUs aren’t getting a boost.  

If you read our blog on the 2024 final rule, you might remember that the Relative Value Update Committee (RUC) was going to consider whether the multiple procedure payment reduction (MPPR) was being improperly applied to the relative value units (RVUs) of 19 therapy-related codes. Well, the results are in, and it’s a bit of a mixed bag. While CMS concedes in the proposed rule that MPPR was in some instances incorrectly applied more than once, the end result is that CMS has opted to go with the direct practice expense (PE) inputs recommended by the Healthcare Common Procedure Coding System (HCPAC) rather than those recommended by the APTA and AOTA—or in other words, the lesser amount. 

Plan of care certification is undergoing a major change—and we think you’ll like it. 

If you’ve ever had to harangue a physician to sign off on a plan of care and felt the pain when they didn’t do so within the 30-day window, there may be some relief in sight. CMS has heard your complaints and is proposing to amend current regulations to allow for a signed and dated order/referral from a physician or NPP to count towards certification requirements—NPP meaning a nurse practitioner (NP), physician assistant (PA), or clinical nurse specialist (CNS). Documentation of that order/referral in the patient’s medical record, and evidence in the medical record that the therapy plan of treatment was transmitted/submitted to the ordering/referring physician (or NPP) within 30 days of the initial evaluation will count towards meeting those requirements. 

We should note that this is only applicable in instances where a patient comes with a signed and dated order or referral from a physician indicating the type of service to be ordered. Additionally, clinicians should still make every effort to get the POC signed and, if the POC is going to extend beyond 30 days, they definitely need that signature.

Supervision guidelines are set to be loosened. 

Another point of contention between therapists and CMS has been the supervision guidelines for PTAs and OTAs providing outpatient services. CMS has long maintained a direct supervision requirement—which, as many providers and advocates have pointed out, is more stringent than the requirements mandated by the state practice acts where they work (44 states, to be more specific). 

Count this as another area where making your voice heard pays off because CMS is set to change its requirements from direct supervision to general supervision for PTAs and OTAs by their respective primary providers. In the proposed rule, CMS notes that its direct supervision requirement may have had the unintended consequence of limiting access to care, particularly in areas where there are limited qualified therapists and the ongoing labor shortage affecting different parts of the country. 

To clarify what they mean by general supervision, CMS states, “(T)he proposal to allow for general supervision would mean that the procedure is furnished under the [occupational or physical therapist in private practice’s (OTPP/PTPP)] overall direction and control, but the OTPP/PTPP need not be present in the treatment location or immediately available.” Perhaps we could say that CMS is arriving at that conclusion a bit too late, but let’s take the wins where we can get them—belated or not.

Virtual direct supervision remains in place…for now. 

The onset of the COVID-19 pandemic forced CMS to adopt new approaches — including allowing providers to meet direct supervision requirements through audio-video communication technology. As soon as providers got a taste of that convenience, it was going to be difficult to unwind those changes—which is why CMS is leaving the relaxed guidelines in place for now. In the proposed rule, CMS proposes to “continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications” through December 31, 2025.

Additionally, CMS is considering making these guidelines permanent for services deemed “inherently lower risk”, which they define as “services that do not ordinarily require the presence of the billing practitioner, do not require direction by the supervising practitioner to the same degree as other services furnished under direct supervision, and are not services typically performed directly by the supervising practitioner.”

Caregiver training services are being fine-tuned.     

The 2024 final rule introduced needed caregiver training services (CTS) CPT codes. These new codes allowed providers to bill for work that, until then, they’d had to either bill under separate, not-quite-applicable codes or simply not bill at all. As with most newly introduced codes and rules, it takes a bit of time to get everything just right, and CMS is proposing some adjustments to CTS codes and payments.  

• On the coding front, CMS is clarifying that “when reasonable and necessary, assessing the caregiver’s skills and knowledge of caregiver training services could be included in the service described by CPT code 96161”.
• CMS is proposing to provisionally include the payable CTS codes (CPT codes 97550, 97551, 97552, 96202, 96203) on the list of telehealth services. 
• CMS is also proposing that, in order to give a health risk assessment to a caregiver, providers must receive consent from the patient or the patient’s representative. 
• On the point of consent, CMS proposes that consent for CTS can be given verbally by a patient, in line with guidelines for other services covered under the PFS.  

Rehab’s permanent telehealth privileges get punted—again.

Ever since the COVID-19 public health emergency (PHE), PT, OT, and speech services have been available on a provisional basis and not a permanent addition. CMS admitted they have received numerous requests to add PT, OT, and speech CPT codes to the permanent list, but at this time they have not made a final decision. Instead, this year they plan to do a “comprehensive analysis of all such provisional codes which we expect to address in future rulemaking.” So, in other words, CMS will decide later once enough time has passed and hopefully let us know the good news.

There are always a few changes to MIPS.

This year’s proposed rule did offer new developments for MIPS, some of them impacting rehab therapy. Perhaps the biggest overall change is on the MVP side, where CMS is proposing to do away with weighting for the Improvement Activities category and allow providers to choose one activity that would count for 40 points. CMS notes that this change is to encourage greater participation in the MVP program.  

We also got some indication of when CMS is thinking of fully transitioning from traditional MIPS to MVPs; CMS indicated that it’s “seeking feedback on clinician readiness for MVP reporting and MIPS policies needed to sunset traditional MIPS in the CY 2029 performance period/2031 MIPS payment year.”

Some things remain the same, however. CMS decided to keep the threshold of 75 points for the CY 2025 performance period (2027 MIPS payment year), citing that “this would provide stability for MIPS eligible clinicians as they become acquainted with the cost performance category (particularly if the scoring methodology).” 

In the meantime, there are always a few tweaks to the program to be aware of, including the PT/OT specialty set, reweighting criteria for MIPS reports categories, and changes to the Rehabilitative Support for Musculoskeletal Care MVP.

Process Measures

Several new measures were added to the specialty set for physical and occupational therapy, and they are open for consideration and comment.

Quality #130: Documentation of Current Medications in the Medical Record

CMS has proposed this process measure to improve reporting efficiency by removing the age criteria so that all patients have documentation attesting to their current medical records. In addition to an assessment, missing information about the dosage, route, or frequency of a medication supports clinical communication and may assist in avoiding patient harm. The measure was further updated to allow for intervention to occur on the day of an encounter as opposed to during the encounter only. This process measure will also be added to pediatric audiology services as applicable to their scope of practice.

Quality #155: Falls: Plan of Care

This process measure was previously collected via the Medicare Part B Claims Measure Specifications, but that has since ended. Therefore, CMS is moving this process measures collection type to the MIPS CQM Specifications for 2024 benchmarking found at https://qpp.cms.gov/benchmarks. 

Quality #181: Elder Maltreatment Screen and Follow-Up Plan

The change to this process measure is somewhat unrelated to rehab therapy, but CMS added emergency department encounter codes to better capture screening for elder mistreatment.

Quality #182: Functional Outcome Assessment Tool

Recognizing that not all patients are able to complete a questionnaire for functional and behavioral limitations, CMS plans to allow clinicians to use a standardized clinical assessment tool instead. Please note that if the patient can complete a questionnaire, this is the preferred collection method.

Quality #281: Dementia: Cognitive Assessment

To improve the consistency of this measure collection, CMS has added the requirement that a dementia diagnosis must be present before the cognitive assessment is administered. 

Quality #282: Dementia Functional Status Assessment

Speech-language pathology was added to this process measure as CMS recognized SLPs as appropriate practitioners to identify changes in functional status in patients diagnosed with dementia.

Quality #286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia

As dementia affects a person’s ADLs (e.g., eating, swallowing, and speech) CMS recognized SLPs as appropriate practitioners to identify and treat changes in functional status in patients diagnosed with dementia.

Quality #288: Dementia: Education and Support of Caregivers for Patients with Dementia

As dementia affects a person’s ADLs (e.g., eating, swallowing, and speech) CMS recognized SLPs as appropriate practitioners to identify and treat changes in functional status in patients diagnosed with dementia.

Quality #281: Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease (PD)

CMS plans to add coding for physical and occupational therapy as these specialties are clinically appropriate to assess for cognitive impairment or dysfunction in patients with PD. The measure description is the percentage of all patients with a diagnosis of PD who were assessed for cognitive impairment or dysfunction once during the measurement period.

Quality #293: Rehabilitative Therapy Referral for Patients with Parkinson’s Disease

This process measure seeks to improve referral loops for patients with PD and adds coding for neuropsychology, behavioral health, and speech-language pathology to report on the percentage of patients with a diagnosis of PD who were referred to physical, occupational, speech, or recreational therapy once during the measurement period.

Quality #498: Connection to Community Service Provider Category

CMS recommends adding PT and OT to the list of denominators who would report on patients 18 years or older who screen positive for one or more of the following health-related social needs (HRSNs): food insecurity, housing instability, transportation needs, utility help needs, or interpersonal safety; and had contact with a Community Service Provider (CSP) for at least 1 of their HRSNs within 60 days after screening.

Outcome Measures

One outcome measure has proposed changes, Quality #503 the Gains in Patient Activation Measure (PAM®) Scores at 12 Months. In the proposed rule, CMS recommends changing the minimum re-administration of the score from six months to four to better capture more reported outcomes. CMS also seeks to lower the minimum performance threshold for collected follow-up PAM® surveys from 50 percent to 25 percent, which would remove patients who were missing more than 3 responses on the PAM-10® surveys or more than 4 responses on the PAM-13® surveys. This is to decrease the burden placed on clinicians as they try to meet the measure’s denominator. Lastly, the proposed rule would increase the number of qualifying visits to two during the performance period and add an exclusion to remove patients who may have died during the performance period.

Rehabilitative Support for Musculoskeletal Care MVP

Last year rehab therapy entered the world of MIPS Value Pathways—a program heralded as the eventual replacement for traditional MIPS. In this year’s proposed rule, CMS has made some adjustments by adding five quality measures, one improvement activity, and a proposal to remove two other improvement activities.

New Quality Measures

• Q050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older
• MSK6: Patients Suffering From a Neck Injury who Improve Pain
• MSK7: Patients Suffering From an Upper Extremity Injury who Improve Pain
• MSK8: Patients Suffering From a Back Injury who Improve Pain
• MSK9: Patients Suffering From a Lower Extremity Injury who Improve Pain

New Improvement Activity:

• IA_ERP_6: COVID-19 Vaccine Achievement for Practice Staff

Improvement Activities to Be Removed

• IA_CC_1: Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
• IA_EPA_1: Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient's Medical Record

Re-Weighting MIPS Categories

As the MIPS program continues to make changes, and its participants continue to try and keep up with a system constantly in a state of flux, CMS has proposed a new exception for reweighting. MIPS participants may request reweighting for one or more of the quality, improvement activities, and Promoting Interoperability performance categories if their submissions were detrimentally affected by a third-party intermediary responsible for the submission. To do so, MIPS clinicians must submit appropriate evidence via a written agreement between the MIPS-eligible clinician and the third-party intermediary on or before November 1 of the year preceding the relevant MIPS payment year.

To help in the application process for MIPS reweighting, CMS has stated they will also be considering: 

• Whether the MIPS participants knew or had reason to know of the issue with its third-party intermediary’s submission of the clinician’s data for the performance category(ies); 
• Whether the MIPS-eligible clinician made reasonable efforts to correct the issue; and 
• Whether the issue between the MIPS-eligible clinician and their third-party intermediary caused no data to be submitted for the performance category(ies) in accordance with applicable deadlines.

If accepted, this proposed rule would go into effect starting with the 2024 performance year (2026 payment year). Lastly, CMS states that this proposal was made purely to try and mitigate any financial harm a third-party intermediary may have caused by submitting no data in the reporting period, and does not limit any liability on the part of the third-party intermediary. 

Another proposal means another chance to weigh in.

Well, that about wraps up the highlights as they pertain to rehab therapy. While it would seem there were fewer rules made, that does not make them any less impactful. As always, now is the time to submit comments and respond to these rules proposed by CMS. To do that, go to the regulations.gov website and click the “comment” button. 

Remember, what CMS does each year is a congressional mandate, so rules like the conversion factor and rate cuts will continue to be levied year after year until Congress decides to change something and enact new legislation. That said, a little advocacy goes a long way so use resources like the APTA’s advocacy networks or APTQI’s Take Action page. In the meantime, we here at WebPT will keep you abreast of all the latest and greatest in rehab therapy and be on the lookout for the final rule in late November.