The 2021 Proposed Rule: An Overview for PTs, OTs, and SLPs

Every year near the end of July, the Centers for Medicare and Medicaid Services (CMS) releases a document with all of the proposed policy changes that it wants to implement in the coming year. And this year, the proposed rule is a roller coaster for rehab therapists. CMS proposed some legislative changes that are indisputable wins for PTs, OTs, and SLPs—alongside some changes and payment cuts that could be seriously detrimental for the entire industry. So, buckle up—and let’s talk legalese. 

CMS will pay more for evaluation services. 

Last year, CMS announced its decision to revalue CPT codes in an effort to direct more payment toward evaluation and management (E/M) services—which PTs, OTs, and SLPs rarely bill. In the 2021 proposed rule, CMS acknowledged that PT, OT, and SLP evaluation services are similar to E/M codes (i.e., they both require assessment and management work) and proposed a modest payment bump for those services.. 

CMS proposed to apply an RVU increase (estimated at 28%) to the following codes: 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 92521, 92522, 92523, and 92524. 

PT and OT payments will see a large overall cut. 

Unfortunately, CMS’s plan to increase E/M and evaluation code payments comes at a price. In order to fund these changes, CMS is proposing to reduce the conversion factor (i.e., the number by which CMS determines all CPT code payments) by 10.61%. The direct result is that PT and OT Medicare payments will experience an estimated 9% cut come January 2021. CMS also specified that the 9% cut estimate already accounts for the proposed increases to therapy evaluation payment. 

There is a beacon of hope at the bottom of this roller coaster drop. By implementing the E/M cuts in this manner, CMS made it easier for Congress to allocate money toward the Medicare budget. So, directing advocacy toward Congress at this time is essential.

Feeling the squeeze from reimbursement cuts? Let WebPT help you maximize your billing and get every dollar you deserve.

PTs, OTs, and SLPs will not receive permanent telehealth privileges. 

Because of the rapid, widespread (and frankly successful) adoption of telehealth across the country, CMS decided to continue to pay for remote care services. However, per the 2021 proposed rule, CMS does not plan to extend permanent telehealth billing privileges to PTs, OTs, or SLPs, citing previous legislation that does not include rehab therapists “on the statutory list of eligible distant site practitioners.”

CMS also proposed to completely omit therapy services from the list of eligible telehealth services, which would prevent therapists from providing and billing telehealth incident-to a physician. CMS is choosing to do this because it believes “that adding therapy services to the Medicare telehealth services list could result in confusion about who is authorized to furnish and bill for these services when furnished via telehealth.”

Other Remote Services

Under this proposal, PTs, OTs, and SLPs will be allowed to provide “brief online assessment and management services as well as virtual check-ins and remote evaluation services.” (Think e-visits, virtual check-ins, and other remote management services.) Telephone services, however, were not included in the proposal. 

To help rehab therapists continue to provide remote services, CMS proposed creating two new HCPCS G-codes that are similar to virtual check-in codes, have the same value, and are specifically intended for clinicians who don’t typically bill E/M services. 

Supervision

Due to the COVID-19 public health emergency, CMS adopted an interim policy that revised the definition of direct supervision, allowing providers to supply such supervision virtually (e.g., via two-way video). CMS is proposing to extend this policy until either the end of the public health emergency or December 31, 2021. 

PTAs and OTAs will be allowed to provide maintenance therapy.

Earlier this year, when CMS published its home health final rule, it declared that PTAs and OTAs could provide maintenance therapy to Medicare beneficiaries in inpatient settings (e.g., SNFs or CORFs). To align Medicare policy across the board, CMS proposed to allow PTAs and OTAs to provide maintenance therapy regardless of setting: 

“We do not believe that the therapist-only maintenance therapy requirement is needed in the case of outpatient physical or occupational therapy services, and instead believe that it would be appropriate for an OT or PT to be permitted to use their professional judgement to assign the performance of maintenance therapy services to an OTA or PTA when it is clinically appropriate to do so.”

Therapy students can assist with documentation.

In the 2021 proposed rule, CMS also clarified that therapy students are allowed to document in the medical record—provided that the billing therapist reviews, verifies, signs, and dates the record. 

Rehab therapists cannot bill remote physiologic monitoring codes. 

CMS also clarified that the remote physiologic monitoring (RPM) codes 99453, 99454, 99457, 99458, and 99091 are E/M services—which “can be ordered and billed only by physicians or nonphysician practitioners (NPPs) who are eligible to bill Medicare for E/M services.” This ultimately means that PTs and OTs will not be able to bill Medicare for these CPT codes. 

MIPS will change only slightly. 

Luckily, the proposed changes to the MIPS program aren’t too complex. Let’s skim over the highlights! But first, if you need a MIPS refresher, check out this comprehensive guide to the program. 

MIPS Value Pathways 

MIPS Value Pathways (MVPs) are a “participation framework” that would unite the activities and measures of the MIPS program and remove the siloed nature of the four categories. CMS was originally planning to have providers transition to MVPs in the 2021 performance year. But, because of the COVID-19 pandemic, CMS is pushing back its timeline and doesn’t intend to implement MVPs until 2022—at least. 

Low-Volume Threshold and Category Weighting

CMS did not propose changes to the low-volume threshold criteria, meaning individual clinicians will still be mandated to participate in MIPS if they: 

• submit Medicare Part B claims for more than 200 unique beneficiaries,
• submit Medicare Part B claims for more than 200 services (i.e., CPT codes), and
• bill more than $90,000 in allowable charges to the Medicare Part B program.

The agency also proposed to retain the MIPS category reweighting of 85% for the Quality Measure domain and 15% for the Improvement Activities domain for PTs, OTs and SLPs.

Performance Threshold 

In recognition of the pressure that COVID-19 has put on our nation’s healthcare system, CMS proposed to lower the performance threshold for the 2021 performance year. If this proposal is finalized, MIPS participants would have to earn 50 or more points to secure a neutral or positive adjustment (instead of the previously required 60 points). The additional performance threshold for exceptional performance is not slated to change from its current 85 points.

Quality Category 

The proposed rule outlined several changes to the measure sets in the quality category. First of all, CMS proposed adding measures 283 and 286 (two dementia measures) to the PT/OT specialty set and removing measure 282 (also a dementia measure) due to its similarity to another measure. Additionally, CMS proposed adding measure 134 (depression screening) to the SLP specialty set.

Beyond that, CMS proposed “substantive changes” to nearly every single clinical quality measure (CQM)—most often reflected in each measure’s denominator. We’ll keep you updated as our MIPS experts parse through the proposed (and eventually finalized) legislation. 

Don’t like the contents of the 2021 proposed rule? Keep your eyes peeled for advocacy efforts led by the APTA, AOTA, ASHA, and WebPT.