October Founder Letter: Avoiding Potential Billing and Compliance Scares

We’re getting more specific ICD-10 codes for Parkinson’s Disease. 

As of October 1, ICD-10 2024 has gone into effect. The most significant coding change in therapy practices is the expansion of diagnoses for Parkinson’s Disease (PD) diagnostic set. The PD code (G20) is being deleted and replaced with five new Parkinson’s codes that are more specific:

• G20A1 PD without dyskinesia, without mention of fluctuations,
• G2A2 PD without dyskinesia, with fluctuations,
• G20B1 PD with dyskinesia, without mention of fluctuations,
• G20B2 PD with dyskinesia, with fluctuations, and
• G20C Parkinsonism, unspecified.
  

If you haven’t already, update your ICD-10 book or application to the 2024 version and your Parkinson’s patients’ diagnoses.

UnitedHealthcare is getting rid of some requirements—and adding new ones. 

In August, United Healthcare (UHC) announced a policy change to require a physician's signature on a therapy plan of care (POC). Fortunately, after significant advocacy efforts, they have walked that back, and it will not be implemented as planned. However, UHC simultaneously announced that start and stop times for treatment will need to be included in the therapy documentation. This change did go into effect, so be sure to include the start/stop times of your visits with UHC/OPTUM.

Aetna is updating its rules for assistants.

Aetna is the next large insurance payer to implement the CMS Assistant de minimus rules and require the CO and CQ modifiers for assistant services. This applies when an assistant delivers 10% or more of a service and results in a 15% reduction to their fee schedule. It is interesting that Aetna, which pays about 25% less than Medicare, wants to discount its already value-reduced payments deeply.

We’re finally getting some prior authorization reform. 

Thanks to significant coverage by the healthcare media on the payer abuses associated with prior authorization programs, we are finally seeing some initial changes in payers rethinking their programs.

• UHC has announced a reduction in prior authorization of services and DME items. These new policies will be going into effect over the fall and include the UHC Community plans, although the cutback is less for those plans than for the other programs.
• Aetna and BCBS of Michigan have also announced programs to be implemented throughout the fall to reduce requirements for prior authorization for therapy services.

Along those same lines, a majority of U.S. states are considering some form of legislation to force payers to rightsize the time-wasting, care-delaying payer practice of prior authorization. In total, nearly 90 prior-authorization reform bills have been considered in this legislative session in 30 states, with more than a dozen still on the table for potential passage.

The biggest potential legislative victory is the news that the powerful House Ways and Means Committee has advanced provisions that would help bring badly-needed reforms to the prior authorization process within Medicare Advantage. The provisions passed last week track closely with the Improving Seniors’ Timely Access to Care Act. That bipartisan legislation was introduced by Reps. Suzan DelBene, D-Wash., Mike Kelly, R-Pa., Ami Bera, MD, D-Calif., and Larry Bucshon, MD, R-Ind. and unanimously passed the House in mid-September. 

Among other things, this law will:

• Establish an electronic prior authorization process.
• Require the Department of Health and Human Services (HHS) to establish a process for real-time decisions for items and services that are routinely approved. 
• Improve transparency by requiring Medicare Advantage plans to report to CMS on the extent of their prior authorization use and the rate of approvals or denials. 
• Encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians.

The proposed rule is adding new codes—and clarifying guidance around existing ones. 

The proposed rule is always hotly anticipated, and this year’s release from the Center for Medicare and Medicaid Services (CMS) is no exception. Here’s some of what we can expect to see in the 2024 Medicare Physician Fee Schedule Final Rule when it’s published to the Federal Register in late October or early November:

• CMS is offering more guidance on remote therapeutic monitoring (RTM) codes.
• Potential clarifications will likely be issued for the RTM codes. In particular, the ability for the RTM codes to be billed in the same month as the Remote Physiologic Monitoring (RPM) codes.
• The issuance of an RTM-specific policy will allow PT and OT assistants to provide these services under general supervision.
• CMS might also clarify issues with billing monitoring codes 98980 and 98981 every calendar month versus billing device codes 98976, 98977, and 98978 every 30 days with the required 16 days of data collection.
• We can expect to see the finalization of Caregiver Training CPT codes and their values.
• CMS has suggested that they might be revaluing 19 therapy codes because of the undervaluing of staff expense part of these codes' Practice Relative Value Units (RVUs).‍
• Telehealth services access will be extended through 2024.
• Direct supervision for therapy assistants may be changed to general supervision from direct supervision. 

Once the final rule is published, be sure to look out for our blog recap and annual December webinar highlighting the rehab-specific changes for 2024.

More rehab therapists are recognizing their value. 

Let’s step away from the specifics of billing and compliance to look at the bigger picture. Regardless of the changes that payers have in store for later this year or next year, the fact remains that there is still considerable downward pressure on fee schedules and payments for therapy services. Some of these changes represent an easing of the administrative burden and costs put on the shoulders of providers, but if rehab therapists want to survive in the long term, practice models need to change and evolve to provide the competitive pay therapists want.