FAQ: Mountains of Regulations: What’s Changing for PTs, OTs, and SLPs in 2021

Introduction

Every seasoned mountain-goer knows that the winter mountain environment is in a constant state of change, and the threat of an icy storm is always looming. Because of this, residents must be ready to adapt to these environmental changes at the drop of the hat—or face the consequences. This year, CMS’s rules also felt like they were in constant flux, and rehab therapists had to work overtime to adapt to the blizzard of changes that pelted their clinics. The biggest changes of all? Contained in the 2021 final rule, of course! That’s why Dr. Heidi Jannenga, PT, DPT, ATC, WebPT Co-Founder and Chief Clinical Officer, and Rick Gawenda, PT, CEO and President of Gawenda Seminars & Consulting, joined forces to host an hour-long webinar that explained the major changes included in the 2021 final rule. During the presentation, they received too many questions to answer live, so we tackled the most common ones here. 

Can’t find the information you need? Drop a comment at the bottom of the page, and our team will do its best to dig up an answer for ya. 

Advocacy and the 9% Cut

Will critical access hospitals (CAHs) be affected by the 9% cut?

No. Critical access hospitals are paid on a cost-ratio basis—not under the Medicare Physician Fee Schedule. That means they will not be affected by the 9% cut.

How does H.R. 8702 affect the payments by non-Medicare payers that, as you said, typically follow Medicare reimbursement guidelines? It seems like it only would stop the CMS reductions, but not necessarily reductions from other payers.

As Gawenda explained during the webinar, many insurance carriers base their payment rates on a percentage of Medicare’s conversion factor. So if, for example, the conversion factor is $36.09, and the payer multiplies that by 1.1 to get its rate, you get $39.70. But if you take the conversion factor to $32.41 x 1.1,  you get $35.65.

If Congress passes this legislation, it will mitigate the reduction. But, we don’t yet know how that will affect the conversion factor, which means we don’t know how it will impact other carriers who use the conversion factor. So, at this point, we just have to wait and see.

Why would these cuts force clinics to see fewer Medicare patients?

At the end of the day, clinics are businesses, and they have to pull in enough money to pay the bills and keep the doors open. If Medicare payments drop low enough, it may no longer be financially feasible for some providers and clinics to treat Medicare beneficiaries. 

When does the public health emergency (PHE) end? Do you anticipate that it will be extended?

Currently, the PHE ends at the end of the day on January 20, 2021. Gawenda speculates that, due to the rising number of COVID-19 cases across the country, the PHE will see another 90-day extension.

Telehealth and Remote Care 

Are therapists no longer able to bill telehealth therapy codes immediately upon the termination of the PHE, or will the coverage go through the end of the year in which the PHE ends?

Coverage of certain therapy codes delivered via telehealth (e.g., 92521–92524, 92507, 97161–97168, 97110, 97112, 97116, 97535, 97750, 97755, 97760, and 97761) will continue through the end of the year in which the PHE for COVID-19 ends. However, PTs, OTs, and SLPs will not retain their temporary ability to perform and bill Medicare for those services once the PHE ends. This means only practitioners who have permanent telehealth privileges (e.g., physicians) will be able to perform and bill Medicare for those services beyond the expiration of the PHE.

Can you bill remote services to patients outside of the state you are licensed in?

Technically, yes, you can bill for remote services provided across state lines. However, you must either be licensed in the state in which the patient is located, or the patient’s state—and the one you’re practicing in—must be part of the PT state licensure compact. Furthermore, keep in mind that you must also be credentialed with the patient’s insurance payer.

Can a progress note be completed remotely? Can the visit be completed with a PTA on site and PT remote?

PTAs cannot complete progress notes, and this has not changed in light of pandemic-related flexibilities. However, during the public health emergency, physical therapists may complete progress notes as part of virtual (i.e., telehealth) visits—whether or not a PTA is involved in the service delivery.

How much does Medicare pay for remote therapy service codes?

Medicare’s 2020 non-facility prices for remote service codes are as follows: 

Telehealth payment is a little different from the other remote service codes, as Medicare is currently offering pay parity to in-person visits. So, if you bill 97530 when the service was provided via telehealth, you should receive the same payment you would had you provided the service in person.

Remember, the payment amounts cited above do not account for the 9% cut—and Medicare will no longer pay for telephone visits in 2021.

Can you explain the differences between the various types of remote services and their CPT codes?

We actually have an entire blog post that covers this topic in depth.

In the 2021 final rule, CMS seems to contradict its intent with G2061–G2063. At one point, CMS says it is finalizing 98970–98972 as replacements for the G-codes, but a few lines down it states PTs, OTs, and SLPs will be able to bill G2061–G2063. I cannot find the new CPT codes listed in our AMA files. Also, the G-codes are not listed as deleted CMS codes. Where can we find clarification that the G-codes are definitely being replaced by the CPT codes?

The final rule is never completely straightforward. Every year, in its roughly 2.000 pages, it contains repetitions and vague statements—often creating confusion until CMS releases clarifying guidance. This year, on page 154 of the final rule, CMS states, “After consideration of the comments received, we are finalizing our proposal to replace G2061–G2063 with CPT codes 98970–98972.” That’s about as clear as CMS gets; it does appear to want PTs, OTs, and SLPs to use codes 98970–98972 in 2021.

It’s also important to note that, in this statement, CMS used the word “replace” instead of “delete.” A code is not removed from the MPFS unless CMS “deletes” it—and CMS usually provides ample notice before doing so in order to minimize burden for EMRs and billing software. As of now, G2061–G2063 are not slated to be deleted—though that may change in the future.

What is the difference between a remote service and a telehealth service?

Within the context of rehab therapy, remote services refer to any clinical services that take place either wholly or partially off of the clinic (or home, in the case of home therapy) premises. This includes e-visits, virtual check-ins, telephone visits, and telehealth visits. So, telehealth is a specific type of remote service. Telehealth includes standard therapy services (i.e., those billed with 97000-series codes, like evaluations or therapeutic exercise) that are provided via a real-time, audio-video connection (like a Zoom call). Check out this blog post for more info.

Can we provide telehealth on a cash-pay basis after the PHE concludes?

Assuming Medicare does not change its policy on reimbursement for telehealth therapy services after the end of the public health emergency—and provided your state practice act allows you to perform these services—then yes, you could conceivably provide telehealth services on a cash-pay basis after the emergency declaration has been lifted.  

Billing and CPT Codes

Is there a code for suture removal—and can PTs get paid for it?

According to the American Academy of Professional Coders (AAPC), there are several codes for suture removal (15850,15851, and S0630)—but PTs cannot bill or get paid for any of them. Two of them can only be billed by a surgeon, and the third can only be billed by a physician. Beyond that, the AAPC says that suture removal is usually rolled into evaluation and management (E/M) services—something that PTs also cannot bill.

Can a PT bill for testing with a hand dynamometer? Would this be included in CPT code 97750?

In some cases, yes. As Gawenda explains in this post, “You can bill this CPT code when you provide a physical performance test and measurement that is separate and distinct from an evaluation or reevaluation.” And as this resource explains, “Sensory/pinch/grip tests” are covered under 97750.

Can a podiatrist bill for PT services? What about a physician?

As noted in this fact sheet, a doctor of podiatry falls under Medicare’s definition of a physician. And as explained in this article, “The only legal way for a physician group to bill physical therapy services to Medicare is to bill those services as ‘incident to’ physician services. To bill under this method, however, the physical therapist must be employed by the physician group or at least be a leased ‘common law’ employee of the physician group. Moreover, the physical therapy services must be ‘incident to’ that physician’s services. That means the physician must have seen the patient at some time to initiate the plan of care.”

Is CPT code 98960 a payable code? If so, what is the appropriate modifier?

That depends on the payer’s policy. Medicare, for example, bundles this code—as do many other payers. However, some payers do not bundle Education and Training for Patient Self-Management codes, so you will need to contact the payer directly for this information.

For more information on these codes, check out this WebPT Blog post.

Will Medicare pay for 99072?

Nope! Medicare has tagged this CPT code with a status indicator of “B.” Essentially, this means that its payment is bundled into the other CPT codes you charged that day (kind of like a hot/cold pack). To learn more about CPT code 99072, check out this post. 

Can non-contracted therapists bill incident-to a credentialed therapist for non-Medicare plans such as BCBS, UHC, Cigna, etc.?

That depends on the payer’s and/or plan’s rules. Contact the payer to determine its stance on incident-to billing for non-contracted or non-credentialed providers.

Is it possible to count non-treatment service time (e.g., time spent gaining subjective information or providing education) toward the total billable minutes?

Yes! PTs can—and absolutely should—bill for assessment and management time. This includes the time PTs spend: 

• Assessing patients prior to an intervention;
• Assessing patients’ response to an intervention;
• Providing instructions, counseling, or advice about care;
• Answering questions from patients and/or caregivers; and
• Documenting during appointments.

You can learn more in this blog post. 

How do we determine whether the patient's Medigap will pay for the Part B deductible or if he or she must pay for it out of pocket?

As explained in this FAQ, “Starting January 1, 2020, Medicare Supplement insurance plans can’t cover the Medicare Part B deductible.” (And as clarified in this post, “Medicare Supplement and Medigap are different names for the same type of health insurance plan – you can use either name.” 

Therapy Assistants and Students

Can a PT student treat and bill for services provided to a Medicare or Medicaid patient?

According to this Medicare guide, “Medicare Part B will not pay for services provided by a therapy student, because students are not licensed providers.” However, as we explain in this blog post, there are some exceptions to that blanket rule. Most notably:

• “The qualified practitioner is recognized by the Medicare Part B beneficiary as the responsible professional within any session when services are delivered.
• “The qualified practitioner is present and in the room for the entire session. The student participates in the delivery of services when the qualified practitioner is directing the service, making the skilled judgment, and is responsible for the assessment and treatment.
• “The qualified practitioner is present in the room guiding the student in service delivery when the student is participating in the provision of services, and the practitioner is not engaged in treating another patient or doing other tasks at the same time.
• “The qualified practitioner is responsible for the services and as such, signs all documentation.”

Medicaid is a little tricker, since the program varies from state to state. Your best bet is to reach out to your state Medicaid program and ask for further clarification. (You can access your state agency’s contact information from the Medicare website.)  

Maintenance Therapy

What exactly is maintenance therapy? Can you provide some examples?

The best way to describe maintenance therapy is to compare it to rehabilitative therapy. The goal of rehabilitative therapy is to treat a patient who has an acute injury—like a torn rotator cuff. As that patient progresses through the designated plan of care, you can expect the patient’s status to improve—eventually to the previous level of function. 

The goal of maintenance therapy, on the other hand, is to maintain a patient’s current level of function or prevent a decline in function. For instance, let’s say a patient has multiple sclerosis. You can’t reasonably expect to improve that patient’s function—but you can help prevent the patient from losing function. This would be the goal of a maintenance therapy plan of care, and as long as your skilled intervention is necessary in helping the patient meet that goal, you can continue billing for your care. 

How do you bill for maintenance therapy?  

Therapists should bill for maintenance therapy the same way they bill for any other therapy. Use the same codes, the same modifiers—the whole shebang. The only difference between maintenance therapy and rehabilitative therapy is the overall goal. Essentially, you’re providing therapy to the patient to prevent a loss or decline in function—not to improve their function over time. Your documentation should support this goal, just as it would in a rehabilitative case. 

Can therapists provide maintenance therapy beyond the therapy threshold?

Yes! Medicare still pays for medically necessary care that’s provided above the therapy threshold—and maintenance therapy is definitely medically necessary for some patients. Additionally, keep in mind that maintenance therapy counts toward the annual therapy threshold.

In what situations can PTAs and COTAs provide maintenance therapy?

Prior to the COVID-19 public health emergency (PHE), PTAs and OTAs could provide maintenance therapy in home health and skilled nursing settings—but were prohibited from providing maintenance care in outpatient settings. CMS allowed therapy assistants to provide outpatient maintenance care to assist with the PHE, and the agency has since decided to make this change permanent. All of that is to say that from here on out, PTAs and OTAs can provide patients with maintenance therapy.

Medicare Participation

Can a non-participating provider treat Medicare patients? If so, what is the maximum amount we can charge?

Yes; PTs can choose to be non-participating Medicare providers and still treat Medicare patients. However, keep in mind that non-participating providers are still in a contractual relationship with Medicare, and while they can bill up to the limiting charge (i.e., a rate that’s higher than what Medicare typically pays), patients will likely have to pay more out of pocket.  

As for the limiting charge, CMS says that it “equals 115 percent of the nonparticipating fee schedule amount and is the maximum the nonparticipant may charge a beneficiary on an unassigned claim.”

If we do not contract with Medicare, can we collect cash from Medicare patients?

That depends, but in general, no. Unfortunately, rehab therapists cannot collect cash for covered services from Medicare beneficiaries—regardless of the therapist’s participation status with Medicare. (Non-covered services like wellness and fitness services are a whole other story. You can read more about that in this blog post.) 

For more information on Medicare and cash-pay services—and what to do if you accidentally accept cash for a Medicare-covered service—check out this post from the WebPT Blog.

Supervision

For incident-to billing, does the physician need to be on site with the PT at all times in order to bill?

Yes. As we explain in this blog post, incident-to services “must occur under direct supervision of a qualified provider.” That said, “direct supervision does not imply that the qualified provider is in the same room, but simply means that he or she is on site and immediately available to assist the rendering provider.”

Does the change to direct supervision of PTAs and COTAs also apply to outpatient Part B therapy in the home?

Yes. The MPFS contains rulings specific to Part B outpatient care, which means that these changes to assistant supervision policies also apply to outpatient home care. Prior to the COVID-19 PHE, therapy assistants required direct supervision at all times, but CMS eased direct supervision requirements for all therapy assistants to ease the burden of the pandemic. Those changes aren’t permanent, though. At this time, they’re set to expire on December 31. Additionally, remember that if your state practice act requires direct supervision for therapy assistants, then you must adhere to those guidelines (i.e., the strictest guidelines that apply to you).

Do you have any guidance on what CMS considers “real-time, interactive audio-visual” supervision?

Real-time, interactive audio and visual supervision refers to any type of telecommunication platform that includes two-way audio and visual communication between the patient and provider that occurs synchronously. Examples include Zoom or Google Meet.

Below are a few examples of communication avenues that would not meet this supervision standard:

• Telephone calls, as there is no visual component.
• Pre-recorded video, as it does not occur in real time.
• Email or text messaging, as it lacks an audio or video component.

Therapy Threshold

Do you feel there is a greater chance of an audit if you go past the $3,000 medical review threshold?

Not necessarily. CMS doesn’t bar therapists from providing care beyond the $3,000 medical review threshold. In fact, billing beyond that threshold won’t automatically trigger an audit. CMS is simply looking for cases of fraudulent billing, so “selection for review is largely based on whether your billing practices differ significantly from your peers.”

How can we keep track of progress toward the therapy threshold?

If you use WebPT for your EMR platform, each Medicare beneficiary’s allowable amount for PT, OT, and/or SLPs services is tracked on his or her patient chart. Furthermore, you can verify the patient’s current amount usage by contacting your Medicare Administrative Contractor (MAC). You can find your MAC’s contact info on this page.

Qualified Medicare Beneficiary (QMB) Program

If a patient is a Qualified Medicare Beneficiary, or has Medicaid coverage, is it lawful to have the patient sign an ABN form and pay directly for services not generally covered by Medicare/Medicaid?

Yes! During this Medicare compliance webinar, compliance expert and legal counsel Veda Collmer, JD, OTR/L, explained “this practice not only protects your practice because it aligns with Medicare’s rules and regulations, but also clearly notifies your patients about what Medicare will and will not cover (so, what they will be responsible for paying out of pocket if they choose to continue).”

In the same webinar, Jannenga added that “the ABN form requires you to share with patients which line items won’t be covered, so after the eval—when you understand which treatment protocols are appropriate—you can provide the ABN to patients and discuss your plan of care, ensuring they understand what to expect from a financial standpoint, thus enabling them to make an informed decision.”

How do you know if a patient is in the QMB program?

As Gawenda explained during the webinar, when you get your remittance advice, you can look for remark code N781 or N782, which indicate QMB status. You can also see this information in Medicare eligibility data or check through your state Medicaid online eligibility system. Also, keep in mind that QMB rules also apply to Medicare Advantage plans.

MIPS 

Is it possible to opt out of MIPS this year due to COVID-19?

Yes. CMS is allowing clinics that have been affected by extreme and uncontrollable circumstances (e.g., the pandemic) to submit an application to opt out of MIPS. If approved, this application can reweight one or more program categories, essentially allowing providers to receive a neutral score (meaning they won’t receive any type of payment adjustment, positive or negative). Take a look at this blog post for more info. 

How do I find out if I have to participate in MIPS?

The easiest way to find out if you’re mandated to report for MIPS is to use the official QPP participation lookup tool. You can find it on this page.

How do PTs see their MIPS scores?

PTs can find their MIPS scores by logging into their QPP account. Alternatively, if PTs are using a MIPS reporting service (like through WebPT), they may be able to access their scores through a separate portal.

Are the MIPS thresholds per therapist or per practice?

The MIPS low-volume threshold is applied at the individual clinician level. So, only individual therapists will be mandated to participate in the MIPS program. Groups will not be mandated to report; however, if a practice chooses to participate as a group, then all clinicians in that practice must participate.  

Miscellaneous

Do any final rule changes impact our practice if we see Medicaid and Tricare patients, but no Medicare patients?

Medicaid regulations are determined at the state level, so changes to the Medicare program do not necessarily affect Medicaid plans. That said, many payers (including Medicaid!) use Medicare’s rulings as a template for their own payment policies, so it’s possible that you will see some of these changes reflected in state and commercial payer policies. As for Tricare, this program uses the CHAMPUS Maximum Allowable Charges (CMAC) to determine reimbursement rates, and “These charges are the maximum amounts TRICARE is allowed to pay for each procedure or service and are tied by law to Medicare's allowable charges.” Thus, changes to Medicare’s payment rates naturally impact Tricare payments.

Do these changes apply to outpatient rehabilitation facilities (ORFs)?

Yes, for the outpatient therapy services ORFs and CORFs bill under the Medicare Physician Fee Schedule.

Will the 2% sequestration adjustment apply in 2021? Is that on top of the 9%?

Yes, sequestration will apply in 2021, and yes, it’s on top of the 9% cut.

Having trouble finding the information you’re looking for? Feel free to leave your gnarliest questions about the final rule below, and our team will try to find you an answer!