CMS 2020 final rule is being met with a lot of confusion and fear. Understanding some of the main points can help healthcare providers to start processing and possibly promote change of the rules.
1. Rehabilitation therapists will see an approximate 8% decrease in Medicare payments
There are proposed evaluation and management code changes, which translates to reduced reimbursement in 2021. At this point in time CMS has not yet decided how it will revalue codes or which codes will be impacted.
Over the next year the APTA states that it will petition CMS to reconsider the reduction in payment. Katy Neas, APTA executive vice president of public affairs stated “Over the next 12 months, we will leverage every possible opportunity—working with Congress and CMS—to change this flawed policy.”
2. Services provided by physical therapist assistants and occupational therapy assistants will be reimbursed at a lower rate than if they were provided by physical or occupational therapists
Reduced payment rate of 85% is scheduled to go into effect in 2022. Starting 2020 CMS will require therapist to apply a PTA and COTA modifier to all outpatient therapy services billed to Medicare Part B. This includes outpatient services provided by CORFs, provided in rural areas and underserved regions. It does not apply to services provided by critical access hospitals or services billed incident-to a physician or nurse practitioner.
3. “In Part” definition was revised.
CMS replaced it’s original definition of “in part” to one that is a little less restrictive. When a patient treatment is delivered as a service team by a therapist and an assistant no modifier will be required. This is a change from the original proposed rule of the modifier criteria impacting payments for all services by a PTA or COTA.
From CMS: “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.”
Therefore, the 10% standard, which requires a CQ or CO modifier when at least 10% of the service is delivered by a PTA or COTA remains, but the modifiers need to be applied only when the PTAs and COTAs provide services on their own and not together with a therapist.
4. Details Of The Claims
Therapists should keep in mind that the CQ and CO modifiers will need to be in addition to the GP and GP therapy modifiers. Also, codes can be split. By this I mean each code can be split up into 15-minute increments to denote PTA and COTA administration of treatment. If a therapist treats a patient for 15 minutes, then an assistant independently treats a patient for the rest of the treatment time, codes can then be split to reflect the modifier for the time of assistant treatment.
5. Removal of Requirement of Narrative Phrases
From CMS: “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.”
CMS went on to say: “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.”
6. CPT Code Changes
Also included are a few changes in CPT codes. Some of the more notable ones are:
- Dry Needling
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)
CMS declined to finalize these codes as “always” or “sometimes” therapy services because, as per CMS: “dry needling services are non-covered unless otherwise specified through a national coverage determination (NCD).”
Therefore, while there are codes for dry needling, Medicare will not pay for them.
Two different biofeedback CPT codes (90912 and 90913) are adjusted to being “sometimes therapy” codes. In other words, these codes won’t be affected by MPPR (multiple procedure payment reductions) and will still contribute to the therapy threshold.
- Cognitive Function Intervention
Two cognitive function codes, 97129 and 97130 will now be considered “sometimes therapy” services. They won’t be impacted by MPPR and continue to contribute to the therapy threshold. Also, beginning 2020 code G0515 will be deleted.
- Negative Pressure Wound Therapy
CMS assigned active status to CPT codes 97607 and 97608. CMS will now determine code rates instead of your local Medicare Administrative Contractor.
7. Raised Threshold
The therapy threshold was raised to $2080, and as long as services are medically necessary therapist can attach the KX modifier to claims.
As you can expect, there are many others points to consider in the 2475 page document. Over the next year keep an eye out for changes, amendments, and additions.