What the CMS 2018 Final Rule has in Store for Therapy-related Services

by | Last updated Dec 15, 2023 | Published on Nov 27, 2017 | Medical Billing

Therapy Related Services
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Ever since the Center for Medicare and Medicaid (CMS) released the final Physician Fee Schedule (PFS) for 2018, medical billing and coding companies have been analyzing its impact on healthcare providers. Under the PFS, payment is made for services furnished by physicians and other practitioners in all sites of service. These services include, but are not limited to visits, surgical procedures, diagnostic tests, specified preventive services and therapy services. Payments are based on Relative Value Units (RVUs) which reflect the relative level of time, skill, training and intensity required of a physician to provide a given service. A recent WebPT article discussed the impact of CMS 2108 final rule on physical therapists (PTs) and occupational therapists (OTs). Here’s a look at what’s in store for these practitioners:

  • Practice expense RVUs: RVUs will continue to be maintained under the PFS. There are changes to work RVU values for PT services. While some RVU values set to increase, some RVUs, which comprise the nonphysician labor within a practice, as well as overhead and equipment expenses, are likely to see a decline. Rehab therapy reimbursements will not be affected in significant way by these changes.
  • Therapy cap: As per the PFS, Medicare therapy caps for physical and speech therapy as well as the cap for occupational therapy will see slight increases in 2018. Additionally, the terms of the exceptions process which govern the use of the KX modifier are set to expire December 31, 2017. The KX may be submitted on physical therapy, occupational therapy or speech language pathology claims only in cases where the condition of the individual patient is such that services are appropriately provided in an episode that exceeds the cap. According to the 2018 PFS, Medicare beneficiaries will be responsible for any claims that go over the cap starting January 1, 2018.
    The WebPT report notes that APTA has been working with Congress to create a permanent therapy cap fix that would eliminate the threat of a hard cap on therapy services and instead require all claims exceeding a primary threshold (which, per the 2018 final rule, is $2,010) to include a modifier denoting medical necessity (provided that the billed services are, in fact, medically necessary).
  • CPT code values: CMS accepted the recommendations of the Health Care Professionals Advisory Committee (HCPAC) for the direct PE inputs for the 19 PM&R codes as well as the three codes for services related to orthotics and prosthetics management and/or training. CMS conducted a comprehensive assessment of the value levels for the following “potentially misvalued” CPT codes and one HCPCS code:
    • 97032 Electrical stimulation (manual) (15 minutes)
    • 97035 Ultrasound (15 minutes)
    • 97110 Therapeutic exercises to develop strength and endurance, range of motion, and flexibility (15 minutes)
    • 97112 Neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities (15 minutes)
    • 97113 Aquatic therapy with therapeutic exercises (15 minutes)
    • 97116 Gait Training
    • 97140 Manual Therapy
    • 97530 Therapeutic/Functional Activity
    • 97535 Self-care/home management training (e.g., activities of daily living [ADL] and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment), direct one-on-one contact (15 minutes)
    • G0283 Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care (Elec stim other than wound )
      Nine additional codes were identified for review by the APTA and AOTA:
    • 97012 Mechanical Traction
    • 97016 Vasopneumatic Device
    • 97018 Paraffin Bath
    • 97022 Whirlpool
    • 97033 Electrical Current
    • 97034 Contrast Bath
    • 97533 Sensory Integration
    • 97537 Community/work Reintegration
    • 97542 Wheelchair Management Training
      Considering the comments received, CMS finalized the HCPAC-recommended work RVUs, including the times, for all of the above-mentioned 19 PM&R codes as proposed. The recommended RVUs include a few increases and do not include any cuts. Initial analysis by the American Physical Therapy Association (APTA) indicates that “overall, the increases and cuts likely balance out”.
  • CPT code changes:
    • CPT codes 29582 (Multi-Layer Compression System, Entire Leg) and 29583 (Multi-Layer Compression System, Upper Arm & Forearm) have been declared redundant and deleted.
    • 97760 (Orthotic Management and Training) and 97761 (Prosthetic Training): For 2018, CPT codes 97760 and 97761 are to be reported only for the initial encounter. The descriptors for these codes have been revised to include the term “initial encounter”. Both codes were previously used to report both the initial and subsequent encounters, that, when furnished under the Medicare outpatient therapy services benefit, included services occurring during the same PT or OT episode of care.
    • 97762 (Orthotic Management and Prosthetic Management) has been deleted and replaced with 977X1 (Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter) for the 2018 benefits year. Per CMS, “CPT-code 977X1 is intended to be reported for all other orthotic and/or prosthetic services for an established patient that occur on a ‘subsequent encounter’ or a different date of service from that of the initial encounter service.”
    • 97532 (Cognitive Skills Development), which is timed code reported at 15-minute intervals is to be in CY 2018. It will be replaced by CPT code 97127 (Cognitive function intervention), which is an untimed code only reported once on each claim.
    • Telehealth: Several therapy-related codes were submitted to CMS to consider for inclusion in its list of billable telehealth services. However, this proposal has been rejected by the agency. Giving the reason for the rejection, CMS’s 2017 final rule noted that several of these services require directly physically manipulating the beneficiary, which is not possible to do through telecommunications technology. Also, CMS noted that PTs, OTs, and SLPs-the providers who perform these procedures-are not currently listed as eligible telehealth providers.

Reports say the impact of final PFS rule on PT and OT practices will depend on the mix of services they offer and their billing patterns. As the new rule becomes operational on January 1, 2018, the support of an experienced medical billing company can be a valuable option to understand the changes and assess its impact on them.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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