Occupational Therapy Assistants/Physical Therapy Assistants Modifier Policy
Despite challenges from National Therapy Associations and other national therapy stakeholders, CMS has proposed Occupational Therapy Assistants and Physical Therapy Assistants payment reduction modifier policy that would reimburse only 85% of the Medicare fee schedule for services that involve both a therapist and assistant if the assistant provides therapy care for more than 10% of the total treatment time in a given therapy session. CMS introduced the CO (COTA) and CQ (PTA) modifiers in the CY 2019 MPFS proposed rule. These new modifiers are to be used on the claim line to identify services furnished by an assistant “in whole or in part” under an occupational therapy or physical therapy plan of care, starting in 2020, with the payment reduction being implemented in 2022. CMS also defined a de minimis standard under which a service is considered to be furnished “in whole or in part” when more than 10% of the service is furnished by the Occupational Therapy Assistants or Physical Therapy Assistants.
In the 2020 proposed rule, CMS proposes calculating the 10% based on the respective therapeutic minutes of time spent by the OT and Occupational Therapy Assistants, rounded to the nearest whole minute. The total time for a service is all the time spent by the OT (whether independent of, or concurrent with the COTA) plus any additional time spent by the Occupational Therapy Assistants independently furnishing the therapeutic service. If an Occupational Therapy Assistants participates in the service concurrently with an OT for only a portion of the total treatment time, the CO modifier would apply when the minutes furnished by the Occupational Therapy Assistants are greater than 10% of the total minutes spent by the OT furnishing the service. CMS also proposes requiring the treatment notes to document why the modifier was or was not applied to the claim for each service furnished that day.
For example, if a therapist performs therapeutic activities for 20 minutes, and the assistant works concurrently with the therapist for 7 out of the 20 minutes, the CO modifier would be required. This is because 7 minutes is 35% of 20 minutes, which exceeds the 10% standard. CMS has proposed this same calculation for untimed services. For example, if the therapist takes 45 minutes to perform an evaluation, and the assistant performs an additional 15 minutes of evaluation services, the CO modifier would be required. This is because 15 minutes is 25% of the total 60 minutes spent performing the evaluation. Again, exceeding the 10% standard.
National Therapy Associations, and other stakeholder groups met with CMS officials several times during 2018 and 2019 to challenge applying the 10% de minimis standard because it is without precedent and difficult to apply. This is especially true in light of the therapy service access issues anticipated in rural and underserved areas under the Occupational Therapy Assistants/Physical Therapy Assistants payment reduction policy set to take effect in 2022.
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KX Modifier, Threshold Amounts, and Medical Review
The CY 2020 proposed rule does not present any substantive changes to the therapy cap repeal, use of the KX modifier, or the targeted medical review process; rather, it clarifies and codifies the changes outlined in the Bipartisan Budget Act of 2018. CMS is proposing adding a paragraph to existing regulations clarifying that the previous annual limitation known as the “therapy cap” is now a threshold amount. Once therapy services billed reach the threshold amount (as determined annually by the Medicare Economic Index and released in November), the KX modifier must be appended to any services billed indicating that the services are medically necessary and are justified as such in therapy documentation.
Quality Payment Program and Merit-Based Incentive Payment System (MIPS)
CMS is also proposing updating the Quality Payment Program (QPP) Merit-Based Incentive Payment System (MIPS). For the 2020 performance year, CMS is proposing increasing the threshold required to avoid a negative payment to 45 points, from 30 points required in the 2019 performance year. CMS is also proposing reducing the weight of the “quality” performance area to 40% of the total score and to increase the “cost” performance area weight to 20%. Therapists have not been required to report cost measures in previous years. National Therapy Associations is analyzing the information to determine whether this will affect occupational therapy reporting requirements. Finally, in the performance area of “improvement activities,” CMS proposes removing 15 activities, modifying 7 activities, and adding 2 new activities. National Therapy Associations is reviewing the improvement activities to identify potential impacts on occupational therapy.
CMS notes that 98% of eligible clinicians participated in MIPS in the 2018 performance year. They also acknowledge that the program is overly complex and burdensome, and needs to be simplified to be meaningful for all clinicians. To that end, they are proposing a new MIPS Value Pathway (MVP) framework that would start no earlier than 2021 performance year. The MVP aims to reduce clinician burden by requiring clinicians to report fewer measures and by calculating more measures using claims and population-level data.
Online Digital Evaluation Service
CMS has approved three new G codes for qualified nonphysician health care professionals to use for online digital assessments.
GNPP1 Qualified nonphysician health care professional online assessment, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes
GNPP2 11–20 minutes
GNPP3 21 or more minutes
CMS proposes recognizing the G codes, but not paying the new corresponding CPT codes, 98X00–98X02, because the CPT codes describe an evaluation and management service rather than an assessment. National Therapy Associations is analyzing this discussion and will submit comments.
Chronic Care Management
CMS has expanded upon the current Chronic Care Management codes by creating new G codes that allow additional time spent within the month to be billed separately. CMS has also created codes for Principal Care Management services, which can be used when the patient only has one chronic condition that is being managed. These new codes will allow specialists to bill for chronic care management services. CMS still does not recognize occupational therapy practitioners as providers for these services, so National Therapy Associations will continue to advocate for occupational therapy to be included.
Evaluation and Management Services
While occupational therapy practitioners cannot perform these services, it is important to be aware that major changes have been made to the evaluation and management or “office visit” codes. Instead of the single level payment rate for level 2–4 outpatient visits previously proposed by CMS for 2021, CMS has adopted the CPT Editorial Panel’s proposed changes. In this proposed model, codes 99201 and 99211 will be deleted, and the 4 remaining levels will be selected based on medical decision making or time. Proposed changes to the E&M codes include increasing the value of all 4 of the CPT code levels and could result in decreases to other CPT codes, including codes that occupational therapy practitioners use, as a result of CMS’ need to maintain budget neutrality. National Therapy Associations is closely analyzing the proposed code value changes to identify any potential reimbursement impacts on occupational therapy CPT codes.
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