On November 1, CMS finalized proposals that impact payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019. CMS estimates that the conversation factor for CY2019 PFS will be $36.03 which is a slight increase from the CY 2019 PFS conversation factors of $35.99.
Two specific policies within the rule will influence therapy practices.
Functional Status Reporting will be discontinued for Outpatient Therapy
Providers of outpatient therapy services have been required to include functional status information on claims for therapy services since January of 2013. The functional status coding and modifiers described patient functional limitation and severity at specified intervals during outpatient therapy services. The data from this system was utilized to assist CMS in recommending changes and reforming of Medicare payment for outpatient therapy services that were subject to the statutory therapy caps. However, due to the repeal of the therapy caps with the 2018 Bipartisan Budget Act, the functional status reporting data became less meaningful. As a result, CMS is finalizing the proposal to discontinue the functional status reporting requirements for services furnished on or after January 1, 2019. However, the KX modifier must be applied when therapy services reach $2,040 for calendar year 2019.
Outpatient Physical Therapy and Occupational Therapy Services Furnished by Assistants
The Bipartisan Budget Act of 2018 requires payment for services furnished in whole or in part by a therapist assistant to be paid at 85 percent of the applicable Part B payment amount for services effective January 1, 2022. CMS is finalizing a proposal to establish two new modifiers to designate when services are rendered by a PTA or OTA.
* PTA Modifier CQ: for services furnished in whole or in part by a Physical Therapist Assistant (PTA)
* OTA Modifier CO: for services furnished in whole or in part by an Occupational Therapist Assistant (OTA)
These modifiers will be “payment” rather than “therapy” modifiers, and will be used along with the current PT (GP), OT (GO), and SLP (GN) modifiers for outpatient therapy services.
CMS is also finalizing a de minimis standard under which a service is furnished in whole or in part by a PTA or OTA when more than 10 percent of the service is furnished by the PTA or OTA, instead of the proposed definition that applied when a PTA or OTA furnished any minute of a therapeutic service. Future rulemaking will further clarify this issue. The new therapy modifiers for services furnished by PTAs and OTAs are required on claims January 1, 2020. The payment reduction for PTA and OTA services will begin January 1, 2022.
Take Home Synopsis
CMS finalized the discontinuation of the Functional Status Reporting (G-Codes) for outpatient therapy services effective January 1, 2019.
- Payment reduction to 85% for outpatient therapy provided by PTAs and OTAs will go into effect January 1, 2022. CMS clarifies that the new modifiers for therapy provided by PTAs (CQ) and OTAs (CO) will be used alongside the current PT and OT modifiers (GP, GO, and GN). CMS explained that the new modifiers (and payment reduction) will apply when more than 10 percent of the service is furnished by the PTA or OTA. These new modifiers will be required on claims beginning January 1, 2020. The payment reduction will begin January 1, 2022.
- For calendar year 2019, the KX modifier must be applied when therapy services reach $2,040.
Click here for the CMS Fact Sheet.
Click here for the Final Rule.
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