CMS Final Rule: The Countdown to 2024 Begins

Every year, the Centers for Medicare and Medicaid Services (CMS) Physician Fee Schedule comes out around the same time—and every year, compliance experts burn the midnight oil to make sense of a document numbering well over 2,000 pages (2,700 pages this time around). Why? Well, part of it is our abiding interest in all things compliance—but the main motivation in doing that heavy lifting is providing busy rehab therapists with the information they need to know in an easily digestible format.   

With that in mind, we have done the dirty work for you to parse the nitty-gritty and winnowed 2,700 pages into the key highlights that will affect you in the coming year. Let’s dive into our year-end coverage of the most rehab-specific pearls you need to know for the physician fee schedule (PFS) in 2024—also known as Medicare’s final rule. 

The conversion factor gets cut once more. 

Another year, another cut to reimbursement. This year’s final rule announced the conversion factor for the 2024 PFS calendar year (CY) would fall to $32.74—a decrease of $1.15 (or 3.4%) from the current CY 2023 conversion factor of $33.89. 

The therapy threshold is changing.

One of the bigger line items rehab therapists are looking for with each year’s final rule is the new therapy threshold. The threshold is the dollar figure Medicare sets for outpatient services that, once met, requires using the KX modifier and, eventually, a targeted medical review (MR) for additional services. In CY 2024, the KX modifier threshold for combined physical therapy and speech-language pathology services—the dreaded Oxford comma strikes again—is $2,330, and occupational therapy services will see theirs at $2,330, as well.

The next threshold to be aware of will be for the targeted MR, and it has been set to $3,000 through CY 2027. Something interesting to note is that with CY 2028, the MR threshold levels will be annually updated by the percentage increase in the Medicare Economic Index (MEI).

Changes are coming to supervision rules. 

The issue of supervision—be it direct or general—has had increased focus within rehab therapy over the last couple of years. With the public health emergency (PHE) and then the introduction of remote therapeutic monitoring (RTM), CMS allowed for changes in how PTs and OTs in private practice (PTPP and OTPP) supervised their assistants—in a limited capacity. 

With the 2024 final rule, CMS has stated that PTPPs and OTPPs can use general supervision of assistants when assistants are using RTM services with patients. Furthermore, the application of general supervision flexibilities to allow for the supervision of assistants through real-time, two-way audio and video will continue through the end of 2024.   

Inevitably, this has opened the door for comments where practitioners have asked to change the direct supervision of assistants in traditional therapy services (i.e., brick-and-mortar clinics) to a general supervision rule across the board. CMS has stated they will continue to monitor this going forward and seek additional comments, but no specific ruling has been given as of yet.

Rehab therapists will get paid for caregiver training.

In an effort to recognize the utility and efficacy of caregiver training, CMS has moved forward with the activation of five new CPT codes that cover caregiver training services under a therapy plan of care established by qualified practitioners for the purposes of a rehab plan of care (POC) or for a behavioral health POC. The caregiver training services (CTS) need to be within the POC and designed to achieve desired patient outcomes. 

CMS further defined a caregiver for CTS as “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.” In delivering CTS, CMS also states that a guardian may be considered a caregiver for these codes when they are caregivers for minor children or other individuals who are not legally independent.

Here are the descriptions of the codes that pertain to PTs, OTs, and SLPs:

• 97550: Caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community (e.g., activities of daily living (ADLs), instrumental ADLs (IADLs), transfers, mobility, communication, swallowing, feeding, problem-solving, safety practices) without the patient present, face-to-face; initial 30 minutes.
• 97551: Each additional 15 minutes listed separately in addition to 97550 for primary services. 
• 97552: Group caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community ((e.g., activities of daily living (ADLs), instrumental ADLs (IADLs), transfers, mobility, communication, swallowing, feeding, problem-solving, safety practices) without the patient present, face-to-face with multiple sets of caregivers.

CMS has specified the work relative value unit (RVU) for 97550 to be 1.00, 97551 to be 0.54, and 97552 to be 0.23 with the assumption that the median group size for 97552 would be five participants. And, since these new codes will be designated as “sometimes therapy codes,” they fall outside the therapy threshold, although the multiple procedure payment reduction (MPPR) does still apply.

The descriptions for the two codes for behavioral health are:

• 96202: Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); initial 60 minutes).
• 96203: Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); each additional 15 minutes listed with primary code 96202.

The work RVU for 96202 will be 0.43 for up to 60 minutes of total time and 0.12 for 96203 once 75 minutes of total time have been reached.

Telehealth is staying around for another year. 

Like general supervision guidelines, this year’s proposed rule generated another round of comments urging CMS to add PT, OT, and SLP to category one or two telehealth distinctions. And, just as in previous years, CMS has remained firm in choosing to keep outpatient rehab services at the category three level. In the final rule, CMS notes that: 

“(d)espite the evidence, we are still uncertain as to whether all of the elements of a therapy service could typically be furnished through the use of only real-time, two-way audio/video communications technology. Because we continue to have these questions, we did not propose to add these services to the Medicare Telehealth Services List on a Category 1 or 2 basis, for the same reasons described in our CY 2018 through CY 2023 rulemaking cycles.” 

However, rehab therapists can enjoy telehealth services for a little while longer. With the passage of the Consolidated Appropriations Act of 2023, telehealth services provided by rehab therapists were given a temporary extension through the end of CY 2024, so rehab therapy can continue business as usual for the coming year.

As always, CMS welcomes ongoing commentary on why PT, OT, and SLP services should be added to category one or category two for future rulemaking. CMS highlights an interesting note from this year’s final rule on that subject that the research submitted to support telehealth thus far served a narrow population (e.g., TKR rehab) and lacked the ability to translate to a broader clinical benefit.” So if you want to see telehealth permanently added as a service for rehab therapists, continue sending in studies and comments during the open periods.  

CMS clarified the use of place of service (POS) codes.

CMS also addressed the ongoing confusion among outpatient therapists on how to apply POS codes when billing for telehealth services. CMS stressed that PT, OT, and SLP distant site practitioners need to apply modifier 95 to identify telehealth services rather than a telehealth POS code. These services will continue to be paid the “non-facility rate” through the end of CY 2024. 

Expanding further on the POS codes, practitioners using code POS 10 will be paid the non-facility rate, while practitioners using POS 2 will be paid the facility rate. Modifier 95 indicates that the applied code was delivered via "synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified healthcare professional and a patient who is located at a distant site from the physician or other qualified healthcare professional."

The Merit-based Incentive Payment System (MIPS) is changing for PTs, OTs, and SLPs. 

CMS is introducing some big changes to MIPS this year—although one key area remains the same. For the 2024 performance year, the performance threshold remains at 75 points, with the data completeness requirement holding at 75% for the 2024, 2025, and 2026 performance periods.  

As far as those changes, CMS has determined that the automatic reweighing of the Promoting Interoperability category will no longer apply to PTs, OTs, and SLPs, although for practices of 15 or fewer clinicians, the Promoting Interoperability category will still be reweighed. Here’s the breakdown of how scores will be weighed for those reporting all four categories: 

• Quality: 30% 
• Cost: 30%
• Promoting Interoperability: 25%
• Improvement Activities: 15%

That said, PTs and OTs aren't required to report on the Cost category, which means their MIPS scores will be weighed across three categories:

• Quality: 55% 
• Promoting Interoperability: 30%
• Improvement Activities: 15%

Also changing is the performance period—CMS has extended the performance period for the category to 180 continuous days, up from 90 continuous days.   

There are more updates to the PT/OT specialty set.

As always, CMS is making additions and subtractions to specialty sets, and the PT and OT sets are no exception. The additions for 2024 are: 

• CQM 291: Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease
• CQM 498: Connection to Community Service Provider
• CQM 502: Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder

Additionally, the measures that were removed are:

• CQM 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
• CQM 178: Rheumatoid Arthritis Functional Status Assessment
• CQM 283: Dementia-Associated Behavioral and Psychiatric Symptoms Screening and Management

Also, while it’s not specifically related to rehab therapy at the moment, providers might want to keep an eye on the newly introduced quality measure CQM 505: Gains in Patient Activation Measures (PAM) Scores at 12 months. 

Rehab therapists have a new Musculoskeletal (MSK) MIPS Value Pathway (MVP).

Perhaps the biggest news for rehab therapists regarding MIPS has been the addition of an MSK MVP for 2024. Granted, it’s been known for some time that the MSK MVP was coming, but it was still a relief to see “Rehabilitative Support for Musculoskeletal Care” as part of the final rule. To get MIPS-participating providers prepared for this new MVP, here’s a quick overview of what’s included:    

Quality Measures: 

• Q217: Functional Status Change for Patients with Knee Impairments
• Q218: Functional Status Change for Patients with Hip Impairments
• Q219: Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments
• Q220: Functional Status Change for Patients with Low Back Impairments
• Q221: Functional Status Change for Patients with Shoulder Impairments
• Q222: Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
• Q478: Functional Status Change
• Q128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan
• Q155: Falls: Plan of Care
• Q487: Screening for Social Drivers of Health

Improvement Activities:

• IA_AHE_3: Promote Use of Patient-Reported Outcome Tools
• IA_AHE_6: Provide Education Opportunities for New Clinicians
• IA_AHE_9: Implement Food Insecurity and Nutrition Risk Identification and Treatment Protocols
• IA_AHE_12: Practice Improvements that Engage Community Resources to Address Drivers of Health
• IA_BE_6: Regularly Assess Patient Experience of Care and Follow Up on Findings
• IA_BMH_12: Promoting Clinician Well-Being
• IA_BMH_15: Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults
• IA_CC_1: Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop
• IA_CC_8: Implementation of documentation improvements for practice/process improvements
• IA_CC_12: Care coordination agreements that promote improvements in patient tracking across settings
• IA_EPA_1: Provide 24/7 Access to MIPS Eligible Clinicians or Groups Who Have Real-Time Access to Patient’s Medical Record
• IA_EPA_2: Use of telehealth services that expand practice access
• IA_EPA_3: Collection and use of patient experience and satisfaction data on access
• IA_MVP: Practice-Wide Quality Improvement in MIPS Value Pathways
• IA_PCMH: Electronic submission of Patient Centered Medical Home accreditation
• IA_PSPA_16: Use decision support—ideally platform-agnostic, interoperable clinical decision support(CDS) tools —and standardized treatment protocols to manage workflow on the care team to meet patient needs
• IA_PSPA_21: Implementation of fall screening and assessment programs

Cost Measure: 

• Low Back Pain

However, there are some areas of concern with the MVP as currently constructed. As noted in the comments portion, a few commenters urged CMS to wait until 2025 to finalize the MSK MVP so that harmonized Limber/IROMS measures could be included as well. At present, the 2024 version of the MVP relies on FOTO measures for seven of the 10 quality measures—which, as the comment notes, are not readily available to many physical therapists and could include additional expenses for access.  

In response, CMS stated: 

“Addressing these previously raised concerns, the measure steward updated the FOTO measures for PY2023 to allow for utilization of a crosswalk, potentially reducing burden for clinicians and their patients who prefer an alternative (legacy) PROMs for reporting of these quality measures. Additionally, the measure steward indicates the FOTO’s Public Access Survey provides a computer adaptive test (CAT) administration of the survey with scoring results provided on the last screen of the assessment without a fee.”

CMS awaits a ruling on MPPR from the RUC.

Earlier this year, CMS mentioned a possible change to the multiple procedure payment reduction (MPPR) for 19 therapy CPT codes’ practice expense (PE) RVUs. As of the release of the final rule, the matter is still awaiting a review and ruling from the relative value update committee (RUC) in early 2024. 

The dense and acronym-filled final rule is never published in a very digestible form. (Would it kill CMS to give us a table of contents?) That’s why we’ve done the hard work for you, highlighting only the areas that apply specifically to the rehab industry. As some of these new rules will continue to have more clarification and use cases, continue to check our blog for new highlights and industry announcements. In the meantime, happy reading!