2019 Proposed Changes You Need to Know About if You Bill Medicare Part B

On July 12, 2018, the Centers for Medicare & Medicaid Services released the Medicare Physician Fee Schedule proposed rule which includes proposals for the Quality Payment Program, all of which govern Medicare Part B payment and quality reporting policies.

The Medicare Fee Schedule sets forth payment policy changes and/or changes to specific CPT® codes and related values. The Quality Payment Program, or QPP, is a product of the finalized rulemaking of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). MACRA ended the Sustainable Growth Rate formula and is designed to shift payment for health care services away from traditional fee-for-service to payments toward promoting reimbursement on the basis of quality care measurement, demonstrated clinical practice improvement, cost efficiency, and promoting electronic interoperability. QPP has a quality reporting aspect as well as an option and incentives to participate in Alternative Payment Models (APMs). QPP can result in bonus payments or penalty payments depending on your composite quality reporting score.

Here are the key Medicare Part B proposals that occupational therapy practitioners need to know about for 2019:

Functional Limitation Reporting (FLR) Discontinued

CMS proposes to discontinue FLR for Medicare Part B claims. This means that occupational therapy practitioners would no longer need to append claims with G-codes as has been required since 2013. AOTA and other therapy organizations have been advocating for the end of FLR for many years due to the administrative and documentation burden on our members. CMS confirmed that with the end of the annual cap on therapy services, the requirement for collecting G-codes is no longer necessary or useful, stating, “we share commenters’ concerns, including those who favor the elimination of functional reporting because it is overly complex and burdensome to report, and those that questioned the utility of the collected data given the lack of standardized measures used to report the severity of the functional limitation being reported.” AOTA considers this to be a significant victory! 

OTA and PTA Modifier Proposed for Use in 2020

The Bipartisan Budget Act of 2018 requires payment for services furnished “in whole or in part” by a therapy assistant at 85% of the applicable Part B payment amount for the service, effective January 1, 2022. For this reason, CMS proposes to establish two new therapy modifiers—one for OT assistants (OTAs) and another for PT Assistants (PTAs). These are to be used in conjunction with the three existing therapy modifiers (GO, GP, and GN) that have been used since 1998 to track outpatient therapy services that were subject to the therapy caps. The new therapy modifiers for services furnished by OTAs and PTAs are not required on claims until January 1, 2020. Payment reductions are not effective until 2022 based on the Bipartisan Budget Act of 2018. AOTA is reviewing this section and related examples closely. Read AOTA’s detailed analysis and learn more about what AOTA is doing to respond to this issue.

We continue to be concerned about patient access to occupational therapy in rural areas. In addition, we are concerned that CMS would require the OTA modifier on claims for OT Evaluations where an OTA provides any services along with an OT, seemingly not permitting the OT and OTA to work on evaluations collaboratively. AOTA is analyzing both legislative and regulatory options to change the “in whole or in part” language to a more appropriate standard. Further, AOTA is seeking a Congressional study to determine possible effects on access to OT. AOTA is also continuing to gather information from OT practitioners in Part B to identify current practices with regard to evaluation contribution, supervision, and billing. See AOTA’s FAQs on the underlying legislation.

Repeal of Therapy Caps Includes Continued Use of KX Modifier

As discussed in detail in the AOTA article, Treating & Billing Without the Medicare Therapy Cap: FAQs. About the 2018 Repeal, the President signed into law the Bipartisan Budget Act of 2018 on February 9, which included a permanent repeal of the cap on Medicare outpatient therapy services.  While therapists are no longer subject to an annual financial limitation of therapy services, CMS does require the ongoing use of the KX modifier to indicate services that are medically necessary above a $2,010 threshold in 2018. $2,010 continues to act as trigger for OT use of the KX modifier for Center for Medicare & Medicaid Services (CMS) record keeping purposes only. The KX modifier is merely a record keeping device through which the therapy practitioner attests to the need for services. The KX modifier is not limiting; it is a claims processing device and should present few problems to therapy practitioners, however, we wish to hear from you if you are experiencing problems. In addition, the BBA18 retains a targeted medical review threshold at the amount of $3,000 for OT services (and 3,000 for SLP and PT services combined), however not all claims exceeding $3,000 are subject to medical review as they previously were prior to enactment of the BBA18.

Codes and Payment Changes

After 2 years of significant changes to both CPT evaluation and treatment codes for OT services, AOTA doesn’t anticipate significant changes to reimbursement for the evaluation or treatment codes OT practitioners bill under Medicare for 2019 as compared with 2020. CMS proposes no changes to the reimbursement rates for the OT evaluation codes and continues to reimburse at the same rate for the low, moderate, and high complexity codes based on the moderate complexity value. AOTA recently posted an article on initial utilization data of the low, moderate, and high complexity evaluation codes and how this data will ultimately help AOTA advocate for stratified code values in subsequent Physician Fee Schedule releases.

OT Merit-Based Incentive Payment System (MIPS) Reporting in 2019

Occupational therapists and physical therapists are included as eligible clinicians for the 2019 reporting year. Therapists who participate in MIPS achieve a score based on quality measures, quality improvement activities, relative cost, and promoting interoperability of electronic health records. Individual occupational therapists (e.g., in private practices) can report via their National Provider Identifier (NPI), or group practices can report through their Tax Identification Numbers (TIN). It is possible that occupational therapists will only be scored on quality measures and improvement activities during the 2019 performance year. Practitioners who participate in 2019 may achieve a reimbursement bonus of up to 7% if successful, or a penalty of up to 7% if unsuccessful, in payment year 2021.

CMS provides a potential exemption from MIPS for smaller private practices through a Low Volume Threshold policy. The policy states that if any one (1) of the following factors is true, the practitioner is not required to report under MIPS:

• Medicare allowed charges of less than or equal to $90,000 or
• Provides covered services to 200 or fewer beneficiaries or
• Provides 200 or fewer services to beneficiaries

However, if a practitioner wishes to “opt-in” to MIPS, they may do so if they exceed any one (1) of the above factors. See the chart below for an example of how the low volume threshold would impact three different practitioners who treat Medicare Part B beneficiaries.

If the Low Volume Threshold is finalized, we anticipate that the majority of OT practitioners will be exempt with the option to opt-in to the program. Occupational therapy practitioners may wish to opt-in if they have significant positive quality reporting experience with MIPS measures; for example, if their practice has actively been voluntarily reporting under MIPS, as permitted since January 2017.

Alternative Payment Models (APMs)

CMS intends to build off of many policies in 2019 (Year 3) that were finalized for Year 2 of the Quality Payment Program but proposes a handful of changes and updates to the Alternative Payment Model (APM) track. By way of a refresher, an APM is a payment approach that gives added incentive payments to clinicians who sufficiently participate in these models by taking on risk when providing high-quality and cost-efficient care. Some of the updates in this proposed rule include: increasing the APM Certified Electronic Health Record Technology (CEHRT) threshold; extending the 8% revenue-based nominal amount standard for APMs through 2024; increasing flexibility for the All-Payer Combination Option and Other payer Advanced APMs for non-Medicare payers to participate in the QPP; streamlining the definition of a “MIPS comparable measure” in both the Advanced APM criteria and Other Payer Advanced APM criteria; Clarifying the requirement for MIPS APMs to assess performance on quality measures and cost/utilization; and updating the MIPS APM measure sets that apply for purposes of the APM scoring standard. AOTA is reviewing each of these proposals to identify relevance for the profession in 2019.

APMs can apply to a specific clinical condition, a care episode, or a population. The following are expected to be Advanced APMs in 2019: the Next Generation ACO Model, Comprehensive Primary Care Plus (CPC+) Model, Comprehensive ESRD Care (CEC) Model (Two-Sided Risk Arrangement), Vermont All-Payer ACO Model60, Comprehensive Care for Joint Replacement Payment Model (Certified Electronic Health Records Track), Oncology Care Model (Two-Sided Risk Arrangement), Medicare ACO Track 1+ Model, Bundled Payment for Care Improvement Advanced, Maryland Total Cost of Care Model (Maryland Care Redesign Program; Maryland Primary Care Program), and the Shared Savings Program Tracks 2 and 3. These are all new delivery models in Medicare. Advanced APMs are growing in importance, so we encourage you to learn more about APMs from AOTA and CMS. Are you already providing OT services in an Advanced APM model? If so, we want to hear from you! Contact us at regulatory@aota.org.

• Read the pre-publication version of the proposed rule entitled, Medicare Program: Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; etc.
• Read CMS’ press release
• Read CMS’ fact sheet

Stay tuned to the AOTA Regulatory Affairs webpage for more information and details as AOTA prepares comments. Comments are due to CMS on September 10, 2018.