The 2020 Final Rule: Health Care’s Just Desserts

Okay, so the title of this article might be a little misleading; the final rule isn’t health care’s just desserts. It’s actually really great that CMS is always trying to improve one of our country’s most important safety nets—even though its methods of doing so are divisive, to say the least. That said, CMS doesn’t exactly make it easy to follow the rules (and I also really wanted to come up with some dessert puns), so keep reading to learn s’more about the 2020 final rule.  

Rehab therapists will get an 8% smaller slice of the Medicare payment pie. 

Unfortunately, CMS decided to move forward with its proposed E/M code changes, which means that, come 2021, therapists will see reduced Medicare payments (which are estimated to drop as much as 8%). However, because CMS hasn’t yet decided how it’s going to revalue codes to execute these cuts—or even which CPT codes will be affected—the APTA intends to spend the next year petitioning CMS to reconsider the changes entirely. “Over the next 12 months, we will leverage every possible opportunity—working with Congress and CMS—to change this flawed policy," said Katy Neas, APTA Executive Vice President of Public Affairs.

PTA and OTA services will bring in slightly less dough. 

Beginning in 2020, CMS will officially require therapists to apply the PTA and OTA modifiers (CQ and CO, respectively) to all outpatient therapy services billed to Medicare Part B that are provided “in whole or in part” by a PTA or OTA. This includes outpatient services provided by inpatient facilities (like CORFs, SNFs, and HHAs)—as well as those provided in rural and underserved areas. However, the PTA and OTA modifiers will not apply to services provided by critical access hospitals, nor to services that are billed incident-to a physician or NPP. The modifiers’ corresponding reduced payment rate of 85% will go into effect in 2022. 

A Revised Definition of “In Part”

There is a nugget of good news buried in the finalization of these cuts. Due in large part to the efforts of the APTA and other industry advocates, CMS rolled back its original definition of “in part” and replaced it with one that’s a little more forgiving.

When a patient’s treatment is ice cream sandwiched between a therapist and an assistant (i.e., when they deliver a service as a team), no modifier is required.

Originally, CMS structured the modifier criteria in a way that would affect payments for all services that a PTA or OTA participated in delivering—even if the assistant was treating alongside a therapist. That requirement has gone out the window. Here’s CMS's explanation of the change: “After a review of commenters’ concerns and our current policies, we are persuaded to reconsider our interpretation of what time counts as services furnished in whole or in part by therapy assistants, including for purposes of applying the 10 percent standard…Instead, we are finalizing a policy that only the minutes that the PTA/OTA spends independent of the therapist will count towards the 10 percent de minimis standard.”

Basically, that means the 10% de minimis standard—which requires CQ or CO modifier application when at least 10% of the service was delivered by a PTA or OTA—still stands, but the modifiers are only required in situations where PTAs and OTAs provide services on their own (not when they treat in tandem with a therapist). 

Claim Details

When applying the PTA or OTA modifiers to a claim, therapists should remember that CQ and CO will be required in addition to the GP and GO therapy modifiers. If a claim includes CQ or CO but omits GP or GO, the claim will be denied.

Providers can make like a banana and split codes for the purposes of modifier application.

Additionally, after considering the many comments and concerns submitted by therapy providers, CMS decided to allow therapists to split up codes in 15-minute increments in order to more accurately denote PTA and OTA treatment administration. For example, if a therapist provides a service to a patient for 15 minutes, and then hands the reins over to an assistant who independently provides the same service for 15 additional minutes, then the service could go on two separate claim lines with two separate codes: one that includes the PTA or OTA modifier, and one that doesn’t. 

Documentation Requirements

The PTA and OTA payment reduction may have put the industry into a stormy mood, but it sure had one heck of a silver lining, because CMS also decided to axe its proposed documentation requirements: “After consideration of the comments and a review of our manual provisions, we find many of the commenters’ suggestions persuasive. We agree that the addition of narrative phrases for each service may be duplicative of existing documentation requirements.” 

Essentially, CMS told therapists to keep on keeping on, because “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, in sufficient detail to permit the determination of whether the 10 percent standard was exceeded.” 

CMS cobblered together a handful of CPT code changes. 

While there was a smattering of CPT code changes included in this year’s final rule, none of them were all that scary (luckily). Here are the big changes that you should know:   

Dry Needling

Well, the folks over at CMS HQ finally pulled the trigger. (Pun very much intended.) Beginning in 2020, there will be two specific CPT codes for dry needling: 

• 20560: Needle insertion(s) without injection(s), 1 or 2 muscle(s)
• 20561: Needle insertion(s) without injection(s), 3 or more muscle(s)

Unfortunately, that’s where the good news for avid dry needlers stops. CMS declined to finalize these codes as “always” or “sometimes” therapy services because, as CMS so delicately put it, “dry needling services are non-covered unless otherwise specified through a national coverage determination (NCD).” So, even though therapists finally have some dedicated dry needling codes, Medicare will not pay for them. 

Biofeedback

Two different biofeedback CPT codes (90912 and 90913) have slightly adjusted RVUs—and are now officially “sometimes therapy” codes. In other words, these codes won’t be affected by MPPR—though they will still contribute to the therapy threshold. 

Cognitive Function Intervention

CMS gave the two cognitive function codes, 97129 and 97130, the same treatment as the biofeedback codes. Their RVUs were tweaked a little bit, and both codes will now be considered “sometimes therapy” services. So, at the end of the day, they’ll sidestep MPPR and still contribute to the therapy threshold. CMS also made a point to clarify that G0515 (a similar cognitive function code) will be deleted beginning in 2020. 

Negative Pressure Wound Therapy

CMS made things a little more uniform by assigning active status to CPT codes 97607 and 97608 (two negative pressure wound therapy services). All this means is that CMS will determine the rates for these codes instead of your local Medicare Administrative Contractor (MAC).

Understanding the therapy threshold should be a piece of cake from here on out.

This year, CMS really wanted to drive home the difference between the old therapy cap and the currently active, much-more-palatable therapy threshold—so it dedicated some space to explaining that, yes, therapists can bill above the now slightly raised $2,080 threshold as long as the service is medically necessary and the KX modifier is affixed to the claim.

And that’s the way the chocolate MIPS cookie crumbles. 

The MIPS program didn’t see many revolutionary changes in this year’s final rule, but CMS definitely raised the bar for MIPS participants, and it’s avidly looking for ways to reduce the program’s burden.

General Program

CMS finalized its proposal to establish the framework of MIPS Value Pathways (MVPs)—a 2021 initiative meant to “simplify MIPS, improve value, reduce burden, help patients compare clinician performance, and better inform patient choice in selecting clinicians.” The goal is for MIPS participants to be able to report on cross-category measures that are connected by specialty or clinical condition—but CMS isn’t sure how to execute this initiative, so it’s seeking input on program development.

The performance threshold (i.e., the score MIPS participants must obtain in order to avoid a negative payment adjustment) went up: in 2020, the threshold will be 45 points, up from 30 points in 2019. The exceptional performance bonus threshold (now called the additional performance threshold for exceptional performance) rose to 85 points, up from 75 points in 2019.

Quality

Starting in 2020, CMS will require all MIPS participants—including those who complete claims-based reporting—to have 70% data completion on all their measures (instead of the 60% that was required last year).  

The PT and OT specialty measure set will boast 12 new reportable measures, but it will also lose two. Additionally, CMS is adding a Speech Language Pathology specialty measure set that will include four reportable measures.

Improvement Activities

The improvement activities category was on the receiving end of its own set of changes. CMS is increasing the number of clinicians in a group who have to complete each activity: in 2020, at least 50% of the clinicians in a reporting group will have to complete each improvement activity in order for a group to attest to its completion. (As explained in this fact sheet, in 2019, “If one MIPS eligible clinician [identified by TIN/NPI] in a group [identified by TIN] completes and attests to an improvement activity, the entire group will receive credit for that improvement activity.”) CMS is also removing 15 activites from the reporting pool, modifying seven, and adding two.

After all of these regulatory changes, I could go for some Stark chocolate.

This year’s final rule also included some changes to the physician self-referral list (a.k.a. the list of services that can violate the Stark Law). CMS added four CPT codes to the list (90912, 90913, 97129, and 97130) and removed seven (90911, 95831, 95832, 95833, 95834, G0460, and G0515).

 And there you have it: an overview of the biggest changes for rehab therapy in the 2020 final rule. If you want to learn more about these impending Medicare changes, be sure to attend our December webinar, MIPS and S’more: 2020 Final Rule Highlights. See you then!