CMS Proposes Reporting Changes for Occupational Therapy in 2019

by | Published on Oct 22, 2018 | Medical Billing

CMS Reporting Changes Occupational Therapy
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Our medical billing company reported on the Medicare 2019 Physician Fee Schedule proposed rule released by CMS, which includes proposals for the Quality Payment Program. These govern Medicare Part B payment and quality reporting policies. CMS has proposed several significant changes to simplify reporting for physical therapists (PTs), occupational therapists (OTs), and speech language therapists (SLTs), and to improve care for outpatient Medicare patients served by therapists. Here is an overview of the proposed changes for occupational therapists billing Medicare Part B:

    • Ending Functional limitation reporting (FLR): Starting July 1, 2013, CMS requiredPTs, OTs and SLTs to complete FLR on all Medicare Part B patients. Aimed at demonstrating the link between rehab therapy and patient progress, FLR required therapists to document each patient’s primary functional limitation (FL), severity of the limitation and the patient’s goal for therapy. This data is submitted using G-codes, corresponding severity modifiers, and therapy modifiers. FL is reported at a patient’s initial evaluation or re-evaluation (if applicable), at minimum every ten visits (as a progress note), and at discharge. The American Occupational Therapy Association (AOTA) has long opposed FLR due to the administrative and documentation burden it imposes on therapists, stealing time from patient care. By proposing to do away with FLR reporting, CMS is addressing these concerns, according to AOTA. CMS stated: “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.”


  • Two new therapy modifiers: CMS proposes to introduce two new modifiers to report the services provided in whole or in part by OT assistants (OTAs) and PT Assistants (PTAs). This measure stems from the Bipartisan Budget Act of 2018 which had required a payment reduction for assistant-provided services effective January 1, 2022. If accepted, this change would require therapy providers to report the new modifiers on claims in 2020. These new therapy modifiers should be used in conjunction with GO, GP, and GN, the three existing therapy modifiers that have been used since 1998 to track outpatient therapy services that were subject to the therapy caps.
  • Inclusion of PTs, OTs, and SLPs in MIPS: The Medicare 2019 Physician Fee Schedule proposed rule includes PTs, OTs and SLPs as MIPS-eligible clinicians for the 2019 reporting year (that is, beginning in the 2021 payment year). Under MIPS, reporting is required under 4 categories-quality, promoting interoperability, clinical improvement activities, and cost. The total annual MIPS score which providers earn determines whether they get a payment incentive, be subject to a penalty, or get the same payment. CMS provides a potential exemption from MIPS for smaller private practices through a Low Volume Threshold policy. The policy states that if any one of the following factors is true, the practitioner does not have 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
    • Practitioners who wish to “opt-in” to MIPS may do so if they exceed any one of the above factors.
  • Continued use of KX Modifier: CMS mandates the continued use of the KX modifier to indicate services that are medically necessary above a $2,010 threshold in 2018, though therapists are no longer subject to an annual financial limitation of therapy services. CMS also references the targeted medical review process, noting the threshold amount of $3,000. However, the proposed rule emphasizes that not all claims exceeding the threshold would be subject to review.
  • Payment changes: Applying the adjustment factors mandated by the Bipartisan Budget Act of 2018 will lead to a slight increase in the proposed fee schedule conversion factor from $35.99 to $36.05. AOTA states that CMS proposes no changes to the reimbursement rates for the OT evaluation codes and will continue to reimburse at the same rate for the low, moderate, and high complexity codes based on the moderate complexity value.

The final rule, which will have significant effects on occupational therapy medical billing and coding, is scheduled to be issued around November 1, 2018.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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