Opportunities created by Medicare Part B 2024 proposed rule

On July 14, 2023, the Centers for Medicare & Medicaid Services (CMS) released their proposed Calendar Year (CY) 2024 Medicare Physician Fee Schedule (MPFS) Rule and Fact Sheet. These proposed payment policies offer ongoing challenges in Medicare Part B reimbursement but also provide new opportunities that, if finalized, could positively impact the delivery of occupational therapy services beginning in January 2024. Key proposed policies important to OT practitioners (OTPs) are outlined below.

Conversion factor

CMS is proposing to decrease the conversion factor for 2024 to $32.75; this is a 3.34% decrease from this year’s conversion factor of $33.89. This is largely due to Congressional requirements for budget neutrality and the expiration of supplemental funds added to the fee schedule last year by Congress.

Therapy providers, including occupational therapists and occupational therapy assistants, have received some of the largest cuts of any provider type, as a result of arbitrary rules governing the Medicare Physician Fee Schedule, such as the Multiple Procedure Payment Reduction (MPPR), lack of inflationary updates, and budget neutrality requirements. In response, AOTA, the American Physical Therapy Association (APTA), the American Speech-Language-Hearing Association (ASHA), and the APTA Private Practice Section have worked to develop a set of policy principles that Congress should adopt to address the unique challenges that have been faced by therapy providers under the fee schedule. These principles are being used to drive legislation that would reform the Medicare Part B payment system by addressing several policies harmful to therapy services.

OT practitioners as telehealth providers

Earlier this year, Congress extended Medicare telehealth waivers through the end of 2024 to allow occupational therapists and occupational therapy assistants (and other therapy practitioners) to continue to provide therapy services to Medicare beneficiaries via telehealth. In this proposed rule, following significant AOTA advocacy, CMS re-affirms occupational therapy approval to bill telehealth services through December 31, 2024, across all settings billing Medicare Part B, including institutional providers such as skilled nursing and long-term care facilities, rehab agencies, and hospital outpatient clinics.

CMS does not have the statutory control to permanently add OT practitioners to the list of approved telehealth providers—this requires an act of Congress. The Expanded Telehealth Access Act would add occupational therapy and physical therapy practitioners and speech-language pathologists to the list of permanently approved telehealth providers. AOTA is actively working with Congressional champions in support of this permanent telehealth fix for the profession.

OTA supervision in private practice

The CMS requirement for direct OTA supervision in private practice settings has been a source of frustration and payment inequity. During the public health emergency (PHE), CMS temporarily allowed direct supervision of assistants to be met through the immediate availability of the supervising therapist via audio/video (A/V) technology. In the CY 2023 final rule, CMS had indicated that this flexibility would cease at the end of the year in which the PHE ended. Given that the PHE ended on May 11, 2023, this meant that without further action by CMS, the ability for OTAs to provide occupational therapy services in private practice would revert back to direct supervision, requiring the supervising OT to be onsite and immediately available during client treatment provided by an OTA after December 31, 2023. However, in another advocacy win for AOTA, CMS has signaled their intent to extend this temporary flexibility to allow private practice direct supervision requirements to be met via the availability of the supervising OT through a/v technology for another year, aligning this temporary policy with the other telehealth flexibilities which extend OTP access to other related telehealth services through December 31, 2024.

AOTA, in collaboration with APTA and ASHA, is actively working toward Congressional legislation that would change the Medicare supervision requirement for OTAs and PTAs in private practice from direct to general supervision. CMS has also stated in this proposed rule that they are considering a regulatory change to update supervision requirements in private practice to general supervision in a future rulemaking cycle. CMS is seeking data and feedback on the benefits of general supervision for OTAs and PTAs over direct supervision and would like to know if there are any patient safety concerns related to a change in supervision level that should be considered. While the extension of direct supervision flexibilities for private practice OTPs remains a temporary fix to a larger issue of unequal supervision requirements for private practice, it does help to preserve client access to therapy services, especially in rural and underserved areas, while more permanent change is being sought through legislative and regulatory channels.

Supervision of Remote Therapeutic Monitoring (RTM) services

CMS has also proposed in this rule to exempt remote therapeutic monitoring (RTM) services provided by therapy assistants from the direct supervision requirement. This rule change, if finalized, would allow OTAs to provide RTM services under general supervision, regardless of practice setting, further expanding the reach of OT services.

Coding opportunities

New caregiver training codes

Over the last year, AOTA, APTA, and ASHA have been working jointly to develop and advocate for payment of three new CPT codes to address caregiver training services. These codes were developed to capture training for a client’s caregivers, in situations where the client themself are not present during the caregiver training session due to issues with scheduling, cognitive deficits, challenging behaviors, or fluctuations in physical capacity or activity tolerance. Skilled caregiver training without the client present was previously non-covered under Medicare programs because the coding definitions of most therapy intervention codes require face-to-face interaction with the client. These caregiver training codes open new opportunities for reimbursement, improved client outcomes, and safer, more effective care transitions. AOTA is thrilled to see CMS acknowledge the important role therapy plays in the delivery of caregiver training through their proposal of payment for these new codes, specifically stating:

“CMS is proposing to make payment when practitioners train and involve caregivers to support patients with certain diseases or illnesses (e.g., dementia) in carrying out a treatment plan. We are proposing to pay for these services when furnished by a (…)physical therapist, occupational therapist, or speech-language pathologist under an individualized treatment plan or therapy plan of care. This proposed action is consistent with the recent Biden-Harris Administration Executive Order on Increasing Access to High Quality Care and Supporting Caregivers, and if finalized, would help support care for persons with Medicare, by better training caregivers.”

AOTA is developing additional resources on how to code, document, and bill these new CPT codes.

Coding for telehealth

During the public health emergency, many CPT codes commonly used by OTPs were temporarily added to the CMS Category III telehealth code list, which is reviewed each year by CMS for additions and deletions. The OT CPT codes previously added to this list were set to expire on December 31, 2023. In this year’s rule, CMS proposes to maintain the therapy codes currently available on the category III temporary telehealth services list through the end of 2024. As a result, occupational therapy services delivered by telehealth will be able to continue throughout the coming year.

CMS also proposes to add the temporary CPT codes related to health and wellbeing coaching services (0591T, 0592T, and 0593T) to the telehealth list on a temporary, category III, basis and include a newly proposed HCPCS code GXXX5 (Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment tool, 5-15 minutes) on the permanent Medicare Telehealth Services List. AOTA continues to monitor the evolution of these codes for potential impact on occupational therapy.

Potentially misvalued codes

When the American Medical Association (AMA) RVS Update Committee (RUC) revalued a group of CPT codes frequently used by OT and PT practitioners in 2018, the valuation process may have misapplied a payment reduction for each code to account for the typical provision of multiple code units during a treatment session. This payment reduction would be duplicative of MPPR, a payment reduction that already occurs after multiple units are billed on the same day. In this proposed rule, CMS is directing the AMA to review the valuation process used for these 19 codes in 2018 to determine if these codes were valued correctly or if potentially duplicative reductions occurred at the time of valuation. Affected codes include:

AOTA staff and member coding advisors are working closely with APTA on this issue, which could potentially positively impact reimbursement rates for these codes if codes are revalued.

Merit-based Incentive Payment System (MIPS)

For the Performance Year 2024, CMS is proposing several updates to the Merit-based Incentive Payment System (MIPS) program that would impact occupational therapy practitioner participation, including new opportunities for OTP engagement with the program.

New quality measures

CMS is proposing new measures be added to the PT/OT Quality Measure set, including:

• Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease. This measure was added to the measure set based on feedback provided by AOTA during the public comment period for measure revision earlier this year.
• A Social Determinants of Health (SDOH) measure related to connecting clients to community services based on SDOH screening
• Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder. This measure was added to the measure set based on feedback provided by AOTA during the public comment period for measure revision earlier this year.
• Gains in Patient Activation Measure (PAM®) Scores at 12 Months*

CMS is also proposing changes to existing measures based on AOTA feedback, including the addition of OT encounter codes to Quality ID: 487 Screening for Social Drivers of Health.

Cost Performance Category

CMS is proposing five new episode-based cost measures for Performance Year 2024:

• Depression
• Emergency Medicine
• Heart Failure
• Low Back Pain
• Psychoses and Related Conditions

When new cost measures are developed, the development contractor convenes a clinician expert panel to advise on measure specifications. AOTA nominates member experts to these panels to represent OT practice during measure development; even with OT member representation, however, measure requirements such as medication prescription or being able to bill evaluation and management (E/M) codes have previously prevented OTPs from being able to participate in cost measure reporting. AOTA member advocacy on the low back pain expert panel was successful in addressing these challenges to OT participation and paved the way for the inclusion of OTPs as attributed clinicians for the Low Back Pain cost measure. This is the first cost measure since MIPS's inception in 2017, for which OTPs have been included as attributed clinicians.

Promoting Interoperability Performance Category

In past years, CMS has noted the exclusion of occupational therapy and other therapy practitioners from the Promoting Interoperability Performance Category due to the limited use of certified electronic health records (CEHRT) and the inability to e-prescribe medications. In this proposed rule, CMS indicates that they are considering the exclusion of clinical social workers for the Performance Year 2024; however, CMS does not indicate whether they will continue to exclude OTPs for this next performance year. AOTA will seek clarification of OT’s exclusion status in our formal comments.

MIPS Value Pathways (MVPs)

MIPS value pathways are a subset of MIPS that align measures and activities across the Quality, Cost, and Improvement Activities categories to offer more meaningful participation in MIPS. MVPs provide more clinically relevant performance measurements and engage more specialists in performance measurement. For the Performance Year 2024, CMS proposes the inclusion of five new MVPs, including:

• Women’s Health
• Infectious Diseases, Including Hepatitis C and HIV
• Mental Health and Substance Use Disorder
• Quality Care for Ear, Nose, and Throat (ENT)
• Rehabilitative Support for Musculoskeletal Care

While most MVPs are geared towards physicians, OTPs can report many of the quality measures included in the MVP measure criteria, making OTPs a valuable team member for positive physician reporting. In addition to assisting with quality measures and improvement activities, the Rehabilitative Support for Musculoskeletal Care MVP was specifically developed for clinicians who specialize in providing rehabilitative support for musculoskeletal care, such as OTPs and represents a previously unprecedented opportunity for improved OT engagement within the MIPS program. AOTA also advocated during the public comment period earlier this year for the inclusion of OT within the Women’s Health and Mental Health and Substance Use Disorder MVPS and will continue to seek additional opportunities for participation as these new MVPs move forward.

Make your voice heard

Each year, CMS publishes its proposed policies to give the public an opportunity to provide feedback prior to finalizing the policies for the following year. AOTA encourages members to learn more about these proposed changes and to comment to CMS on the policies that will affect their OT practice. This is our profession’s opportunity to make our voices heard on policies that will have a significant impact on OT reimbursement and Medicare Part B beneficiary access to OT services in the coming year. Members can also share feedback by emailing regulatory@aota.org.

OTPs are strongly encouraged to submit individual comments to CMS regarding the CY2024 Medicare Physician Fee Schedule. AOTA has developed a template comment letter that can and should be modified to personalize comments. Comments can be submitted via Regulations.gov and are due by 5 pm ET on September 11, 2023.