FAQ: MIPS and S’more: 2020 Final Rule Highlights

Okay, we’ll admit it: it’s probably the worst time of year to go camping. (It may not snow a whole lot in our lovely desert home, but even our December nights have gotten so, so bitterly cold.) But, that didn’t stop Heidi Jannenga, PT, DPT, ATC, WebPT Co-Founder and Chief Clinical Officer, and Rick Gawenda, PT, CEO of Gawenda Seminars & Consulting, from hosting an hour-long camping-themed webinar where they talked about ghost stories and s’mores—and a handful of CMS’s 2020 regulatory changes. And when our fireside experts opened the floor to our audience, they received a flood of questions—too many to answer live! So, we compiled and answered the most commonly asked ones. Go ahead and take a look!

• MIPS
• Low-Volume Threshold
• Program Eligibility
• Optional Participation
• Group Reporting
• Performance Threshold and Reimbursements
• Quality Category
• Improvement Activities Category
• WebPT
• Other
• Final Rule
• PTA and OTA Modifiers
• TRICARE
• KX Modifier and Therapy Threshold
• New CPT Codes
• Other
• Miscellaneous

MIPS

Low-Volume Threshold

How do I know if I’m eligible for MIPS?

MIPS eligibility is determined by something called the low-volume threshold. The low-volume threshold is a set of criteria CMS put in place to excuse providers with small Medicare populations from participating in MIPS. You are required to participate in MIPS if, during both segments of the determination period (i.e,. from October 1, 2018–September 30, 2019 and from October 1, 2019–September 30, 2020), you, as an individual provider, have:

• billed more than $90,000 in Part B allowable charges; and
• evaluated and/or treated more than 200 unique Medicare beneficiaries; and
• provided more than 200 covered professional services under the Medicare Physician Fee Schedule.

If you have not met all three of these requirements, then you are not required to participate in MIPS—though you can choose to opt in if you have met two or three.

What is considered a “covered professional service” with respect to the low-volume threshold criteria?

As we wrote in this blog post, “‘one professional claim line with positive allowed charges’ is considered ‘one covered professional service.’ That means CMS is counting the number of billable codes on each claim—not the number of billable units.”

So, if we bill three CPT codes and two units each, how many covered services is that?

This would count as three covered services (as long as there are positive allowed charges for each).

Where do I go to see if I’m mandated to participate in MIPS?

You can view your 2020 participation status using this handy lookup tool from CMS. Make sure to look at PY 2020, and keep in mind that CMS will not notify you if you’re mandated to report.

Did the low-volume threshold change from 2019?

Nope; the low-volume threshold for the 2020 performance year is the same as it was in 2019.

Is the low-volume threshold based on Medicare claims only, or does it include all claims?

The low-volume threshold pertains only to Medicare Part B claims.

Is the low-volume threshold the same across specialties?

Yep; the low-volume threshold (i.e., the eligibility criteria for MIPS) is the same across all specialties.

Program Eligibility

Will MIPS participation become mandatory in 2021 regardless of the low-volume threshold?

Although some healthcare experts predict that MIPS will eventually become mandatory for all Medicare providers—similar to the now-defunct PQRS program—CMS has not released any official communications confirming its intentions to mandate across-the-board MIPS participation.

I am a single-provider clinic, and I’m not eligible to participate in MIPS as an individual or group. Will I be penalized if I don’t participate in MIPS?  

No. If you’re not mandated to report in MIPS (i.e., you don’t meet or exceed all the criteria from the low-volume threshold), then you will not be penalized if you don’t participate in MIPS.

When does CMS measure MIPS eligibility? In other words, will my 2020 eligibility be determined from October 2017 through September 2018?

While the two segments of the determination periods do run from October 1 through September 30 of the next year, they actually begin only two years before the reporting period. So, for the 2020 reporting year, the first half of the determination period will run October 1, 2018–September 30, 2019, and the second half will run October 1, 2019–September 30, 2020. Because the second determination segment bleeds into the performance year, CMS has previously said that it will provide clinicians “quarterly snapshots” so they can monitor their eligibility.

Are facilities that bill Part A (e.g., CORFs or ORFs) eligible to participate in MIPS? What about hospitals?

MIPS is a Medicare Part B program, so facilities that exclusively bill Part A are not eligible to participate. As we explained in this blog post, “Generally speaking, CORF and ORF-based therapists are not eligible for MIPS—and neither are providers in SNFs or facility-based outpatient therapy. This has to do with how the organizations bill.” Furthermore, “Unless CMS plans to change the TIN and NPI criteria that defines a MIPS-eligible clinician, it’s unlikely that these providers will be included in the future.” That being said, if you’re looking for definitive confirmation of your eligibility—or ineligibility—you can enter your information into CMS’s official participation lookup tool.

Are providers who practice in critical access hospitals (CAHs) eligible to participate in MIPS?

As CMS explains on this page, “If you practice in a Critical Access Hospital (CAH), you may be eligible to participate in MIPS but there are some differences in how the payment adjustment would be applied.

• If you practice in a Method I CAH, the payment adjustment would apply to services you bill under the Physician Fee Schedule (PFS), but not to the facility payment. The payment adjustment works the same way if you practice in a Method II CAH but have not assigned billing rights to the CAH.
• If you practice in a Method II CAH and have assigned billing rights to the CAH, the payment adjustment would apply to the Method II CAH payments.”

Is there any possibility that rehab agencies could be eligible for MIPS at some point, especially with the 8% cuts on the table?

We won’t say that it’s not possible, but at this point in time, it’s looking unlikely that rehab agencies will be included in MIPS. CMS uses NPIs to determine whether an individual clinician meets or exceeds the low-volume threshold—but therapy services billed to Medicare Part B on a UB-04 by institutional providers (e.g., hospitals, SNFs, and rehab agencies) do not contain the individual therapist’s NPI. Until CMS changes that claim format or the method by which it judges the low-volume threshold, rehab agencies will not be included in MIPS.

Can PTAs participate in MIPS?

No. PTAs are not eligible to participate in MIPS.

Optional Participation

What does it mean to opt in or voluntarily report for MIPS? What is the difference between the two?

If you choose to opt into MIPS, it means that you will be fully engaged with the MIPS program—just like providers who are required to participate. In other words, you will fully submit all required data to CMS, and based on that data, you will receive a positive or negative payment adjustment.

If you voluntarily report, then you are essentially participating in a “practice” version of MIPS. You will submit the same data as every other MIPS participant, and you’ll receive a score after the performance year; however, you won’t receive a payment adjustment.

If you opt in one year but decide to opt out after a year, will you still incur a payment adjustment for the first year?

Yes. Leaving the program does not absolve you from previously incurred penalties or incentives.

Group Reporting

If none of the therapists in a practice meet the MIPS participation criteria individually—but the group as a whole does meet the criteria—are we all required to participate?

No. Mandated participation is assessed at the individual level. The group could elect to opt in, in which case all members of the group would be held accountable for the group’s success. Or, individual therapists could opt in (and their scores would be assessed the same way scores are calculated for all other individuals who participate, including those who are mandated).

Can you please elaborate on the difference between individual and group participation?

Participation determinants are always based on individual NPIs; a group is any two (or more) NPIs assigned to the same TIN. So, let’s say that Rick and Heidi work at the same private practice and, individually, neither of them meets the minimum participation threshold. If they still want to participate, they can combine their numbers. As long as together, those numbers exceed one of the low volume threshold criteria, then they can opt in to participate as a group in 2020. However, they are not required to do so.

If everyone in my practice qualifies individually, is it best for us to participate individually or as a group?  

That depends on the makeup of your group. If you have six PTs in a given practice, and you decide to participate individually, then each provider is on his or her own. Perhaps four do well and two don’t—meaning those two therapists may receive reduced reimbursements two years later. But, if you participate as a group, then the four high performers might be able to help boost the lower-performing two and ultimately, benefit the group as a whole. As we explained in the Eligibility section of this MIPS FAQ, “The advantage of reporting as a group is that success is calculated as the average of performance for all therapists, rather than on individual therapist performance scores. The catch is that the decision to report as a group means all therapists in the practice will have to participate, not just the mandated ones.”

If a PT works in a physician practice that is participating as a group, does the PT have to participate as well?

If you’re a PT in a multidisciplinary practice—a POPTS environment, for example—and the physicians are reporting as a group, then you would technically contribute to the group’s score. That being said, if there are many more physicians than therapists, and the physicians satisfy all of the reporting requirements, there’s a good chance the group will be successful regardless of whether the therapists report. On the other hand, some practices may want the therapists to report alongside the physicians, because the therapists may outperform the physicians.

What is a virtual group?

A virtual group is a selection of individual MIPS-eligible clinicians who have come together to report for MIPS as a group—regardless of specialty or location.

Performance Threshold and Reimbursements

How many points do we need to successfully participate in MIPS in 2020?

In 2020, MIPS participants will need to earn a minimum of 45 overall points to avoid a negative payment adjustment. Any score above 45 will earn a positive payment adjustment—and any score of 85 points or more will earn a positive adjustment plus an additional exceptional performance payment adjustment.

Can you give more clarification on performance threshold points—and maybe give an example of how it is applied on the PT’s end?

For detailed explanations of how MIPS scoring and eligibility work, check out this resource.

How are payment adjustments assessed? How will we know what our reimbursements will be?

Payment adjustments are determined by your final MIPS performance score—in addition to the final performance of every other MIPS participant. MIPS is a budget-neutral program, which means that the positive adjustments are completely reliant on the performance of your peers (i.e., if there are more poor performers, you’re in for a bigger positive adjustment—and vice versa). While you can guarantee yourself a positive payment adjustment in 2022 by scoring more than 45 points in 2020, it’s impossible to know what that final payment adjustment will be. For more on this topic, check out our Unwrapping MIPS webinar.

Do adjustments follow individual NPIs or TINs?

Adjustments are assessed by both NPI and TIN, but they end up following providers based on their NPIs. In other words, if you participate, receive a payment adjustment, and move to another practice within the next two-year period, that payment adjustment will follow you to your new employer with a different TIN. It’s important that both practice owners and individual providers take this into consideration. For individual providers, it’s essential that you not rely on your practice’s assessment of eligibility and instead check your own. If you are required to participate, then you must.

How will my clinic’s MIPS adjustment be affected if a PT who was reporting as part of another group starts working at my clinic mid-year?

MIPS scores (and adjustments) follow individual clinicians. So, if a PT participated in MIPS in 2019 with one TIN, then his or her MIPS score would affect whatever he or she billed to Medicare Part B in 2021—even if the therapist were employed by a new TIN.

In other words, that payment adjustment (whether positive or negative) would only affect the claims billed by that individual therapist. The payment for services provided by everyone else in the TIN would only be affected by their original MIPS score—assuming they participated in 2019.

Do you think we should participate in MIPS to help mitigate the upcoming 8% and 15% Medicare payment reductions?

We don’t want to give a blanket recommendation about MIPS, because frankly, every clinic is going to have different financial needs and reporting capabilities. That said, we no longer believe that therapists should dismiss MIPS out of hand. As Heidi Jannenga wrote in this founder letter, “My thought is that this may be a way for therapists to make up for the steady stream of downward adjustments that we can’t seem to escape. However, I want to emphasize that MIPS isn’t an added revenue guarantee, and some practices might still be better off avoiding the program altogether.”

If our practice decides to not participate in MIPS, what is the ultimate reduction we should expect—and by what date?

If the individual therapists in your practice are mandated to report for MIPS and fail to do so, then each therapist who was mandated to report will see a 9% decrease to his or her Medicare payments during the 2022 calendar year. However, if only one therapist in your practice was mandated to report for MIPS in 2020 and failed to do so, then only his or her claims would incur the full 9% penalty during the 2022 calendar year.

Quality Category

We’re a small practice. Which measures should we report?

This answer will vary based on each clinic’s (and therapist’s) individual patient population. If you never see patients with shoulder impairments, for example, then you shouldn’t report measure 221: Functional Status Change for Patients with Shoulder Impairments. The key is to choose measures that are relevant to your day-to-day practice.

How many measures do I have to submit for the quality category?

MIPS participants must report six measures—or every available measure in the applicable specialty measure set—in order to receive full marks in the quality category.

Which process measures can PTs, OTs, and SLPs report in 2020? What about non-FOTO outcome measures? Is there a list I can look at?

Here is a list of all of the different measures that PTs, OTs, and SLPs can report. Keep in mind that these are not all confined to each specialty set—and it may not be in every provider’s best interest to report outside of his or her specialty set.

PTs

• 126: Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy
• 127: Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of Footwear
• 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan
• 130: Documentation of Current Medications in the Medical Record
• 154: Falls: Risk Assessment
• 155: Falls: Plan of Care
• 181: Elder Maltreatment Screen and Follow-Up Plan
• 182: Functional Outcome Assessment
• 217: Functional Status Change for Patients with Knee Impairments
• 218: Functional Status Change for Patients with Hip Impairments
• 219: Functional Status Change for Patients with Foot and Ankle Impairments
• 220: Functional Status Change for Patients with Lumbar Impairments
• 221: Functional Status Change for Patients with Shoulder Impairments
• 222: Functional Status Change for Patients with Elbow, Wrist, or Hand Impairments
• 282: Dementia: Functional Status Assessment
• 283: Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management
• 286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
• 288: Dementia: Education and Support of Caregivers for Patients with Dementia
• 478: Functional Status Change for Patients With Neck Impairments

OTs

• 128: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan
• 130: Documentation of Current Medications in the Medical Record
• 134: Preventive Care and Screening: Screening for Depression and Follow-up Plan
• 154: Falls: Risk Assessment
• 155: Falls: Plan of Care
• 181: Elder Maltreatment Screen and Follow-up Plan
• 182: Functional Outcome Assessment
• 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
• 217: Functional Status Change for Patients with Knee Impairments
• 218: Functional Status Change for Patients with Hip Impairments
• 219: Functional Status Change for Patients with Foot and Ankle Impairments
• 220: Functional Status Change for Patients with Lumbar Impairments
• 221: Functional Status Change for Patients with Shoulder Impairments
• 222: Functional Status Change for Patients with Elbow, Wrist, or Hand Impairments
• 282: Dementia: Functional Status Assessment
• 283: Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management
• 286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
• 288: Dementia: Education and Support of Caregivers for Patients with Dementia
• 478: Functional Status Change for Patients With Neck Impairments

SLPs

• 130: Documentation of Current Medications in the Medical Record
• 134: Preventive Care and Screening: Screening for Depression and Follow-up Plan
• 181: Elder Maltreatment Screen and Follow-up Plan
• 182: Functional Outcome Assessment
• 226: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

In 2019, CMS provided a list of every single reportable quality measure here. CMS will likely update that list in the coming weeks, so make sure to keep your eyes peeled for more details!

How can I report the required outcome measure if I don’t sign up with FOTO?

Unfortunately, if you don’t pay for FOTO or a registry service that includes CMS-approved outcomes measures (like WebPT’s MIPS solution), then you have to report by hand—which involves a lot of spreadsheet-maneuvering and number-crunching. Here are the steps you must follow:

• “Go to the FOTO website, read the measure-reporting instructions, and download all applicable surveys, codebooks, and instructions.
• Administer the FOTO surveys on paper and calculate the scores (including risk adjustment) by hand.
• Record the risk-adjusted summary score in the visit note.
• Use a designated spreadsheet to select the appropriate FOTO measure reporting code that indicates performance of the quality action.”

Is the depression screener measure also designed for for children with neurological impairments?

Unfortunately, we can’t say for sure. The language in the measure specifications is fairly vague, so it’s tough to say whether or not the measure was designed with specialized patient populations in mind. That said, this measure could potentially apply to children with neurological impairments. Here’s the language from the 2019 measure specifications: “Report at least once per performance period, per patient seen who is at least 12 years of age and has been screened for depression using an age-appropriate, standardized tool. If the patient tested positive, the provider created—and documented—a follow-up plan.”

Improvement Activities Category

How many improvement activities do I have to complete for this category?

MIPS participants must attest to 40 points’ worth of activities to successfully complete this category. That shakes out to completing:

• two high-weighted activities,
• one high-weighted activity and two medium-weighted activities, or
• four medium-weighted activities.

Small practices, however, only have to attest to 20 points’ worth of activities. That shakes out to:

• one high-weighted activity, or
• two medium-weighted activities.

Where do we go to attest for the improvement activities category, and by what date is this required?

If your MIPS QCDR doesn’t provide an improvement activities attestation portal, then you’ll need to log into the QPP website to attest. You must attest to your improvement activities by March 31 of the year following the performance period; however, we recommend finishing your attestation sooner rather than later.

If we have two MIPS-eligible therapists but seven total therapists in the group, does 50% of the entire clinic have to complete improvement activities?

If your therapists have elected to report as a group, then all of the therapists who bill under that TIN (i.e., all seven) will have to report for MIPS—and therefore, 50% will need to attest to completing improvement activities. However, if your two MIPS-eligible therapists are reporting for MIPS as individuals, then only they need to complete improvement activities.

WebPT

How will WebPT help PTs, OTs, and SLPs comply with MIPS in 2020?

WebPT’s MIPS reporting tool is built directly into our EMR, so you can fulfill quality measure reporting requirements as you document. And—because our EMR is a CMS-approved registry—we’ll submit all of your MIPS data to CMS on your behalf. We’ve also bundled Outcomes with MIPS to streamline workflows with easy-to-use intake options and automated risk-adjusted calculations for outcome measures.  

How can you view and track your MIPS progress in WebPT to ensure you are meeting the requirements for the quality and improvement activity categories?

Members will receive access to a compliance portal through WebPT’s MIPS partner, Healthmonix, where they can attest to improvement activities as well as view real-time score updates and other information that will help them make timely decisions to close gaps in performance.

How much is WebPT’s MIPS solution?

WebPT’s bundled MIPS and Outcomes solution will cost $379 per provider in 2020. Keep in mind that this includes everything you need for MIPS—quality reporting, improvement activity attestation, outcome intake options, and periodic performance updates throughout the year.  

Would WebPT consider doing a webinar to show us the daily flow of collecting MIPS information within the EMR?

Absolutely! We’re actually hosting a webinar on January 15, 2020 that will cover this information—and everything else you’d want to know about WebPT’s MIPS solution!

Other

When will MIPS become a requirement for all therapists in outpatient?

At this point in time, we can’t say for sure. Some compliance experts are predicting that CMS will remove the low-volume threshold sometime in the future—but if CMS chooses to keep it in place, then some practices and low-volume providers may never have to participate.  

How will MIPS participation look for someone in a niche practice who typically only sees 50 Medicare patients a year—for one visit each?

For the foreseeable future, providers who see a very low volume of Medicare patients won’t be required to participate in MIPS. And, in this case, it likely wouldn’t make sense for your practice to opt in. Even if MIPS does become a requirement for all outpatient therapists, it’s likely that CMS would provide a way for low-volume practices to participate without disproportionate risk of a financial penalty.

If a small clinic does not meet the threshold to participate as a group or individually, are there any direct financial benefits to investing in the infrastructure and processes required to report MIPS?

This is a surprisingly difficult question to answer! There’s no concrete way to assess the ROI of investing in the infrastructure and processes necessary to participate in MIPS, because there’s no guarantee of what the incentive might be. Because this is a budget-neutral program, the size of the payment incentives will rely totally on the size and number of penalties that are distributed.

What are advanced APMs?

According to this CMS resource, “Advanced Alternative Payment Models (APMs) are a track of the Quality Payment Program that offer a 5 percent incentive for achieving threshold levels of payments or patients through Advanced APMs. If you achieve these thresholds, you become a Qualifying APM Participant (QP) and you are excluded from the MIPS reporting requirements and payment adjustment.”

What is the overall reason for CMS to institute MIPS? What do they hope to achieve? Is anyone fighting this implementation?

As we explained in this guide, MIPS is “a consolidation of several legacy programs—the Physician Quality Reporting System (PQRS), the Meaningful Use (MU) program, and the Value-Based Modifier (VM) program.” It’s “a streamlined, one-stop shop for CMS to measure quality and provide financial incentives for eligible clinicians to improve their level of care.” While the therapist professional associations (e.g., APTA and AOTA) continue to provide feedback to CMS about its implementation decisions and the subsequent impact on rehab therapists, there is no stopping it. In fact, we’d argue that therapists are better off spending advocacy energy to minimize the impact of the 8% cut (here are some ideas for doing just that).

Final Rule

PTA and OTA Modifiers

Which settings will these modifiers apply to? Will they apply to critical access hospitals?

As per the 2020 final rule, these modifiers will apply to all outpatient services that are paid under the Medicare Physician Fee Schedule—including those provided by inpatient facilities (e.g., CORFs, SNFs, and HHAs). These modifiers will also apply to those who provide outpatient services in rural and underserved areas. However, these modifiers will not apply to critical access hospitals, because they are not paid under the Medicare Physician Fee Schedule.

Will the assistant modifiers apply to all outpatient services provided by a PTA or OTA?

For the most part, yes. However, the modifier is not required if the service provided by the PTA or OTA is a service that a tech or aide could provide.

Are the CQ and CO modifiers only for Medicare, or for all payers? What about Medicare Advantage plans or Medicaid?

The CQ and CO modifiers are Medicare modifiers; however, some commercial payers are beginning to adopt these Medicare guidelines. With that in mind, you’ll likely want to check in with your individual commercial payers—including those that handle Medicare Advantage plans—to determine their stance on assistant-provided services and modifiers. Medicaid is a state-run program; thus you’ll need to check with the Medicaid agency in your state.

Are there additional documentation requirements to go along with adding the assistant modifiers?

Nope! CMS originally planned to require additional documentation to justify the use or omission of the assistant modifiers, but the agency eventually decided against it: “We would expect the documentation in the medical record to be sufficient to know whether a specific service was furnished independently by a therapist or a therapist assistant, or was furnished ‘in part’ by a therapist assistant but decided against it.”

I know PTAs aren’t allowed to help with an evaluation, but can they provide patients with direction on completing their home exercise program on the day the evaluation is performed—or would that be considered part of the evaluation? To which service would you apply the CO modifier?

In most cases, assistants should be able to provide guidance on home exercise programs on the day of an evaluation—assuming, of course, that the therapist has established the plan of care and provided instructions to the assistant. The evaluation would remain a therapist-provided service, and the modifier would apply to the exercise unit billed.

How will the 10% rule be applied to passive modalities and supervised modalities such as EMS and traction? If the PTA set the patient up on this type of modality, is that considered 10% of the treatment time?

On untimed modalities, the consensus is that the PT and PTA aren’t working together on the passive modality. Thus, if the PTA set up the patient on the modality, then that unit of service would be billed with the assistant modifier. For services like unattended e-stim, you’d need to factor in whether the assistant provided at least 10% of the total service. For example, let’s say a therapist spent three minutes with a patient to educate him or her on the modality before the PTA spent three minutes setting up the e-stim and letting it run for 10 minutes. In this case, three minutes is more than 10% of a 16-minute service, so you would apply the assistant modifier along with the therapy modifier.

Here’s another example. Say a PTA and a PT work together to provide a patient with 40 minutes of therapeutic exercise (97110). The PT works with the patient for 25 minutes, and then the PTA subs in and separately provides the patient with another 15 minutes of therapeutic exercise. Altogether, you can bill three separate units of 97110. However, because the PTA only provided one of those three units, you can split the units up onto two separate claim lines. The line with two units (i.e., the ones provided by the PT) would not require the assistant modifier—and the line with one unit (i.e., the one provided by the PTA) would require the CQ modifier.

Will billing with the PTA modifiers in 2020 result in payment reductions for services provided in 2020?

CMS is requiring the PTA and OTA modifiers in 2020, but the 15% payment differential will not kick in until 2022. This is to help therapists and their billing vendors adjust to the new modifiers before it affects anyone’s finances.

If a PT and PTA work on two patients during the same hour (e.g., the PT works on patient A while the PTA works on patient B, and then they switch patients), how is the 15% reduction applied?

The reduction would apply to individual services for which the PTA provided at least 10% of the service independently of the therapist. For a complete breakdown of the math—as well as example scenarios that help explain how to apply it—check out this blog post.

What does it mean for a PTA or OTA to provide care “independent” of a therapist?

If a PTA or OTA is providing treatment to a patient and a PT or OT is not directing or simultaneously providing care to that patient, then the PTA or OTA is providing the service “independently.”

Here’s an example: say a PT and PTA are working together to provide a patient with gait training. The PT needs the PTA’s help, because the patient has a complex case. When the PT and PTA work together on the same patient and provide care as a team, the service will get billed without the PTA modifier. However, if the PTA provides the gait training to the patient and the PT is preoccupied somewhere else, then the PTA modifier would be required. For more example scenarios, be sure to check out this blog post.

How will the CQ and CO modifiers work in WebPT?

Users of the current version of SOAP notes will be able to use the additional modifier functionality in Company Settings to add the modifiers and make them available for use during a visit. We’re also adding functionality for our next-generation SOAP 2.0 system to comply with the requirement. If you’re a WebPT Member, visit this page to learn more.

TRICARE

If a patient has TRICARE as a secondary or tertiary payer, can a PTA treat him or her?

In this article, compliance expert Rick Gawenda advises against having PTAs or OTAs treat any TRICARE patients when TRICARE is billed as the primary or secondary insurance.

Are SLPAs authorized TRICARE providers?

Currently, SLPAs are not authorized TRICARE providers—and according to Gawenda, there are no current plans to authorize them.  

Is there any info on how ATCs fall into the world of PT as far as treating TRICARE patients—and how ATCs will be affected by the reductions coming in the coming years?

According to this document, CMS does not recognize certified athletic trainers as providers, and as such, they likely aren’t included in CMS’s payment policies. As far as TRICARE, earlier this year, the National Athletic Trainers’ Association (NATA) met with members of Congress to request inclusion in the National Defense Authorization Act, thereby granting ATCs recognition as authorized providers under TRICARE. However, we’ve yet to learn about their decision.

KX Modifier and Therapy Threshold

At what point should we begin using the KX modifier?

You should use the KX modifier when billing for medically necessary services above the therapy threshold ($2,080 for PT and SLP combined and $2,080 for OT in 2020). To learn more, refer to this blog post.

What if a patient comes in and he or she has already exceeded the therapy threshold for the year (i.e., he or she has already received services from another therapist)? Can I still treat the patient?

You would treat this patient the same way you’d treat any other patient who exceeds the threshold. If your services are medically necessary, you would bill using the KX modifier. If your services are not medically necessary, but the patient wishes to receive care anyway, you could have him or her sign an ABN in order to pay cash.

New CPT Codes

What is the difference between “sometimes therapy” and “always therapy” CPT codes?

As we wrote in this FAQ, “According to this CMS resource, all outpatient therapy (OPT) services furnished by therapists in private practice are ‘always considered therapy services, regardless of whether they are designated as “always therapy” or “sometimes therapy.” As such, the appropriate therapy modifier must be included on the claim. However, it may be clinically appropriate for physicians and NPPs to furnish OPT services that have been designated “sometimes therapy” codes outside a therapy plan of care—in these cases, therapy modifiers are not required and claims may be processed without them.’”

Is Medicaid going to use the new dry needling codes? Will these codes be reimbursed?

Medicaid is administered at the state level, so each state has its own billing and compliance requirements. We’d recommend reaching out to your state’s Medicaid agency to learn its stance on dry needling in 2020.

How soon will the CPT code updates be added to WebPT?

The new CPT codes are already loaded into the system, but they will only be available for dates of service after December 31, 2019 (i.e.,you can start using them January 1, 2020). The opposite holds true for the retired codes; they won’t be available for dates of service after December 31, 2019.

Are the dry needling codes untimed?

The new dry needling codes will be untimed, meaning you’ll bill for one unit regardless of how long you spend providing the service.

If you use electrical stimulation with dry needling, can you charge for the electrical stimulation?

Yes! According to our resident billing expert, John Wallace, you may bill for unattended electrical stimulation (97014) when using it at the same time as dry needling.

Do we need to have Medicare beneficiaries sign ABNs prior to collecting payment for dry needling?

Because dry needling is considered a non-covered service under Medicare, providers are not required to have a patient-signed ABN on file before collecting payment from the patient. That said, Gawenda recommends that providers have their patients complete a voluntary ABN in this scenario. This ensures patients fully understand that they are financially responsible for the entirety of the service.

Other

What PT specific services will see an 8% decrease in payments?

We don’t know yet—and CMS doesn’t, either. Keep your eyes peeled for more updates on our blog!

Miscellaneous

What are the supervision requirements for PTAs providing Part B services in a patient’s home?

As we wrote in this blog post, “According to Rick Gawenda, the Medicare Part B program requires PTAs to practice under direct supervision (i.e., the supervising therapist must be physically onsite) in private practice settings. This includes private practices providing outpatient therapy in a patient’s home. In non-private practice settings, Medicare only requires general supervision (i.e., the supervising therapist must provide initial direction and period course-correction, but he or she does not have to be onsite).”

What is going on with payments for home health agencies? We’ve been hearing about major reductions.

While our expertise lies in outpatient billing and payments, the APTA has provided extensive coverage of the new payment methodology that applies to SNFs and home health agencies. You can review those resources here.

Is WebPT going to eliminate the FLR section anytime soon?

Although CMS no longer requires FLR, some insurances still do, so we kept the FLR section in the WebPT EMR and made it optional. You can easily turn off this functionality using your insurance settings if you’d no longer like to see it. WebPT Members can visit this Knowledge Base page to review specific instructions on how to do this.

The campfire is dying down, and it’s time for us to call it a night—but you don’t have to! If you have any burning questions that are keeping you awake, feel free to drop ’em below. We’ll take a crack at finding an answer so you can get back to your s’mores ASAP.

‍