CMS released the Physician Fee Schedule (PFS) Proposed Rule, or the “Medicare Part B Rules” outlining what will kick in 1/1/22, unless changes are made prior to the release of the Final Rule later this fall.
This 1,747 page document includes information on payment rate changes, modifiers, telehealth and more! We highlighted the Medicare Part B rules that are most pertinent to SNF therapy professionals.
So let’s take a look….
What Do SNF Therapists Need to Know for January 1st, 2022?
1. Rate Information
Last year, big cuts were expected for therapy services [9%] due to the re-valuation of multiple Current Procedural Terminology (CPT) Codes… the billing codes therapy professionals use to identify evaluation and treatment procedures for SNF residents. The value of CPT codes used mostly by physicians, called Evaluation and Management Codes (E/M) was increased, therefore, in order to maintain a neutral budget, other CPT codes needed to take the hit, including CPT codes used by PT, OT and Speech. These code value changes were made last year, however, the cuts were decreased from 9% to 3.5% when Congress intervened with $3 billion. Still a cut…but less severe.
This year, it’s no surprise that CMS proposed continued cuts [3.75%], and no word of a monetary intervention from Congress is in sight!
What was cut? Let’s talk about the Conversion Factor.
The Conversion Factor (CF) is a value that CMS modifies yearly. The CF is part of the formula that determines the dollar amount for each CPT code by converting Relative Value Units (RVU), and impacts all CPT Codes across the board. When the CF decreases, the overall payment rate for the CPT codes decrease, unless the RVU for a specific CPT code is increased significantly.
The CF has not been trending in a favorable way over the past 3 years!
Keep in mind that these cuts may impact therapy providers differently due to other characteristics that factor into rate determination, and particular CPT code billing patterns utilized by providers.
In the Rule, the OT Evaluation CPT codes 97165-97167 are proposed to have a technical error correction which would normally increase reimbursement for these codes slightly, however, with the overall CF cuts, there is still a net decrease.
Did you know you can look up any CPT code and check the rate HERE ?
2. Payment Reduction for PTA and OTA Services
The time has come. The CQ and CO modifiers that have been in use for 2 years to identify when therapy services are provided “in whole or in part” by an assistant [PTA or OTA] will now finally translate to reimbursement reduction for services on or after 1/1/22. Medicare currently pays 80% of the PFS allowed charge and the resident (or other payer) pays the remaining 20%. On 1/1/22, Medicare will transition from paying 100% of that 80%, to paying only 85% of that 80%. The remaining 20% is still the patient’s responsibility, though this is not always collectable in the SNF due to Medicaid or other limitations.
| Current status: | Of the allowable charge: | Medicare pays 80% / Patient pays 20% |
| On 1/1/22: | Of the allowable charge: | Medicare will only pay 85% of their 80% portion / Patient pays 20% |
We will continue to use PTA Payment Modifier CQ and OTA Payment Modifier CO on claims to identify when services are provided by an assistant, if the CMS established criteria for “in whole” or “in part” is met, and will have the ability to divide the same CPT code into more than 1 line item for the same day on the claim so the modifiers can be used only when necessary.
How does CMS define when the CQ and CO modifiers are required?
The Proposed Rule provides an overview, and makes some positive changes to prior criteria that make more sense when looking at a treatment session that is provided by both a therapist and assistant on the same day.
- CMS is defining in whole as provision of the full service by an assistant
- ie: The assistant provided the full treatment
- CMS is defining in part as provision of more than 10% of a therapy service by an assistant
- ie: The assistant provided >10% of a “service”
CMS is defining therapy service as a “procedure” identified by a HCPCS code {A.K.A. CPT Code}. On a Part B claim, each “procedure” is identified line by line to include CPT codes, units and modifiers. The new modifiers would be added specifically to the procedure line item to show an assistant provided treatment that met the de minimis standard.
More to come on examples of when the modifiers are needed. For now, it’s important to recognize that these changes are sure to impact therapy scheduling of treatments, and documentation will need to reflect enough information for a reviewer to determine how much time an assistant spent on each portion of the treatment (how much time toward each CPT code) in order to determine if a modifier is necessary.
3. Virtual Services and Telehealth
Virtual Services is the umbrella category where Telehealth lives. Virtual Services encompass Telehealth, E-Visits, Virtual Check-Ins and Telephone E/M services.
Therapists were not able to provide telehealth services prior to the Public Health Emergency (PHE) and are currently only able to provide telehealth now through waiver authority under section 1135(b)(8) of the Act, in response to the PHE for COVID–19. Why? Because CMS removed restrictions in section 1834(m)(4)(E) of the Act on the types of practitioners who may furnish telehealth services.
At the conclusion of the PHE for COVID–19, these waivers and interim policies will expire, and payment for Medicare telehealth services will once again be limited by the requirements of section 1834(m) of the Act.
CMS has reiterated in the Proposed Rule that they do not have the authority to deem therapy professionals as approved telehealth providers.
What does this mean for therapists?
When the PHE ends, all temporary rules, including allowing therapy professionals to provide telehealth, will end. There will be some “therapy” codes that remain in effect through the end of 2023, but even though these codes will live, therapists will not be able to provide and bill Medicare for these services, as our temporary permissions will have expired (don’t forget that others professionals can bill these codes too).
There is current legislation, the Expanded Telehealth Access Act [H.R. 2168], in the works now to try to make PT/OT/SLP approved providers of telehealth by permanently adopting the policy that is temporarily in place due to the Public Health Emergency (PHE).
CMS provided the updated list of Telehealth CPT Codes for the PHE duration on 7/19/21. You can download the list here:
The Proposed Rule also discusses CPT code G2252 (introduced in 2021 for non-therapy providers), and a new set of Remote Therapy Management (RTM) codes (989×1, 989×2, 989×3, 989×4, 989×5) that at this point, will not be for therapists to utilize. However, CMS is seeking feedback on these RTM codes for possible classification that would allow therapy providers to use them in the future. More on these later….
4. Direct Supervision by Interactive Telecommunications Technology
Currently, due to the PHE temporary rule set, the Medicare rule around supervision has been modified to include providing direct supervision via audio-visual technology through 12/31/2021. The Proposed Rule discussed the possibility of making this permanent policy, thus removing the need for direct supervision for Medicare reimbursement.
Of note, this does not impact the SNF setting specifically as Medicare Part A and Part B in the SNF currently require “general supervision,” meaning a therapist does not need to be in the room or on site in order for an assistant to provide services. Medicare Part B supervision rules for Private Practice, however, are more strict.
Do not confuse this rule with your State Practice Act requirements for supervision. This is only a Medicare payment regulation based on Medicare’s definition of Direct Supervision. Therapy professionals must abide by their discipline State Practice Act which may require on-site supervision, and would supersede the Medicare rule.
Important Links and Resources
In Summary
Cuts, cuts and more cuts seem to be the theme for 2022. Let’s hope we get some good news with our professional associations continued advocacy efforts prior to the end of this year.
Remember, these changes are for Part B therapy only, and specific to the SNF setting. We teased out the parts of the Rule that applied to the SNF….so don’t worry about MIPS or other rules specific to private practice!
The Proposed Rule comment period is open through September 13, 2021. Comments can be submitted electronically for this regulation to http://www.regulations.gov. Follow the “Submit a comment” instructions.
As always, if you have any questions about the information or how it will impact you, send them to us here:
In Your Corner,
Dolores Montero, PT, DPT, RAC-CT, RAC-CTA
SNF Therapy & MDS Compliance Team