First, the bad news: The final 2024 Physician Fee Schedule rule rolled out by the U.S. Centers for Medicare & Medicaid Services contains virtually the same cuts to payment under Medicare Part B as were in the proposed rule. But this time around, there’s also good news: Many of the more positive elements in the proposed rule also remain, as does the possibility for future favorable shifts, particularly around PTA supervision. While final rule’s 3.4% reduction to the conversion factor shows the agency continuing down an unsustainable path that will require both short- and long-term congressional intervention, several of the provisions set to be put in place Jan. 1 are clear advocacy wins for APTA and its supporters.

Here’s an overview of the major elements of the final rule. (For additional insights, join us on Nov. 16 for a live webinar on the final rule. It’s free for APTA members and available at a significantly reduced rate for non-members.)

The conversion factor cuts are harmful, but they could’ve been worse, and KX modifier thresholds were adjusted.
The final rule includes another decrease in the conversion factor, one of the elements used in calculating final payment amounts for various codes. This time around, the conversion factor as initially reported by CMS is $32.7375, a 3.4% decrease from the $33.8872 conversion factor adopted in 2023. The impact of the cut is far-reaching, affecting more than 27 specialties including physical therapy.

While still damaging, the cut was less than the anticipated 4.2% drop. The reason, according to CMS, is that it reconsidered utilization estimates of a particular evaluation and management add-on code, which in turn allowed the agency to lessen the cuts to the conversion factor. CMS must make the reductions to the conversion factor to offset the evaluation and management increases in order to maintain budget neutrality.

Now that the final rule has been issued, the only possibility for relief from the cuts comes by way of Congress, which could step in with last-minute appropriations, as it did for the past three years.

APTA will be advocating for a similar short-term fix this year. At the same time, the association will continue its press for long-term solutions, pointing to the cuts as symptomatic of an outdated payment system. APTA, APTA Private Practice, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association have presented Congress with a set of policy principles as a first step toward an overhaul.

Also in the final rule: CMS set the threshold for use of the KX modifier — the modifier indicating that a service meets the criteria for a payment ceiling exception — at $2,330 for PT and speech-language pathologist services combined, and $2,330 for occupational therapy services. The Medical review threshold remains at $3,000 through 2027.

The practice expense elements for 19 therapy codes could potentially increase.
In early 2023, APTA made the case to CMS that several codes frequently used by PTs are subject to a kind of double jeopardy that unfairly cut values. The association offered two arguments: First, that   codes including therapeutic exercises, neuromuscular reeducation, gait training, and therapeutic activities were undervalued by the AMA Relative Value Scale Update Committee, or AMA RUC, that sets payment rates typically adopted by CMS; and second, that these codes simultaneously were subject to reductions associated with the Multiple Procedure Payment Reduction system. APTA asserted that both devaluations are being made for the same ostensible reason — to account for a duplicative practice expense when multiple codes are used on the same day. APTA told CMS that discounting codes twice for the same rationale didn’t make sense.

CMS listened, and in the final rule directs the AMA RUC to re-review its earlier value recommendations — a provision unchanged from the proposed rule. The list of affected codes can be found on Page 96 of the final rule. The codes up for reconsideration have already been added to the AMA RUC’s January meeting agenda; APTA believes that the values of many of the codes will be increased.

New caregiver training codes are on the books.
In another win for APTA, CMS finalized the adoption of codes that would allow PTs, OTs, SLPs, and other providers to bill for providing training to caregivers when a patient with a functional deficit is not present. APTA created the codes, submitted them for AMA consideration, and argued for their valuation levels at the AMA RUC level.

The final rule includes a definition of caregiver that’s broader than CMS’ earlier definition, which had limited the term to relatives of the beneficiary. The new definition, strongly supported by APTA, expands “caregiver” to include “an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation,” and “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.”

The codes, found on Page 285 of the final rule, will be considered “sometimes therapy” and thus not subject to the Multiple Procedure Payment Reduction system. Despite APTA’s advocacy otherwise, the codes won’t be eligible for use in association with telehealth.

CMS provided clarifications on telehealth coding and reporting remote therapeutic monitoring treatment management codes.
CMS followed through from the proposed rule and corrected its mistake that excluded PTs in institutional settings from participating in the telehealth extension that is in place through 2024. Under the final rule, these PTs can participate in telehealth in the same way as PTs in private practice settings — by using the same 95 modifier that they’ve been using since the beginning of the public health emergency. The CMS decision settles, for now, the issue of whether PTs would be required to use new Place of Service codes that CMS adopted. They aren’t.

Also in the final rule, CMS responded to a criticism from APTA that requiring 16 days of monitoring for codes 98980 and 98981 — treatment management codes that account for time spent in a calendar month — isn’t appropriate for these types of services. CMS agreed, and clarified that the 16-day collection requirement doesn’t apply to the two codes.

The rule features more positive movement on PTA supervision, including deeper consideration of general supervision in private practice settings, an extension of virtual supervision allowances, and relaxation of supervision associated with RTM.
The proposed rule included a request for comments on the possibility of moving away from direct supervision of PTAs and occupational therapy assistants in private practice — currently the only setting under Medicare in which 100% on-site supervision is required — in favor of general supervision. APTA made this topic a central feature of its comments to CMS on the proposed rule and urged members to do the same in their individual letters to the agency.

While the final rule doesn’t change the current requirement, it does include a lengthy discussion of the evidence APTA and other commenters provided, including reference to a report commissioned by a coalition of provider groups including APTA that found that a change to general supervision of PTAs in private practice settings could result Medicare savings of $271 million over 10 years. CMS offered its standard language on comment solicitations in the final rule, stating that “we will take these comments into consideration for possible future rulemaking” — but the sheer length of the discussion in the rule may be a good sign.

The final rule also follows through on a proposal to extend virtual supervision of PTAs and OTAs through the end of 2024, and finalizes a general supervision-only requirement for PTAs performing remote therapeutic monitoring regardless of setting.

PTs get their first-ever opportunity to participate in the MIPS Value Pathways Program by way of the first cost measure they’ll be able to report — and will begin MIPS reporting on interoperability.
The rule finalizes several proposed changes to the PT’s role in the CMS Quality Payment Program, or QPP, specifically within the Merit-based Incentive Payment System, or MIPS, and its MIPS Value Pathways program, or MVP.

First, the rule incorporates a new, APTA-recommended MVP based on musculoskeletal care, with a single — and also first-ever — cost measure PTs can use on low back pain. The rule also calls for APTA and other entities to submit existing measure recommendations through the MVP maintenance process, and to work with measure developers to create additional measures for inclusion in the MIPS measure inventory.

Second, CMS will no longer exempt physical therapy practices of 16 or more clinicians from the promoting interoperability category of MIPS, which will in turn require practices to have certified electronic health records technology in place for at least six months in 2024 (practices of 15 or fewer clinicians will still qualify for the exemption). Bottom line: All clinicians (except for clinical social workers), including PTs, will have their MIPS scoring weighted normally in the interoperability category in the 2024 performance year. The change wouldn’t apply to hospital-based clinicians and clinicians in small practices. APTA will issue extensive guidance on how to comply with the new QPP policies in the coming weeks.

Want to take a deeper dive into the 2024 fee schedule?  Join us on Nov. 16, 2023, for a special edition live webinar led by APTA staff: CMS 2024 Physician Fee Schedule Final Rule. The event, which offers CE credits, is free to APTA members and available to non-members at a significantly reduced rate. Register today and spread the word.

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The U.S. Centers for Medicare & Medicaid Services has released the proposed 2024 Medicare Part B Physician Fee Schedule, and, as always, it’s a mixed bag of good and not-so-good news.

Unfortunately, as in previous years, payment cuts are a part of the proposal. This time around, however, other upsides are more prevalent than they’ve been in a while, with many of the welcome changes directly related to APTA advocacy efforts.

In a statement on the proposed fee schedule, APTA President Roger Herr, PT, MPA, characterizes the additional cuts — the fourth round of cuts in as many years — as “unacceptable” but notes that several provisions of the rule will have a positive impact on PTs, PTAs, and patients. Herr’s statement also presses lawmakers to make wide-ranging reforms to the fee schedule system in line with policy principles developed by APTA, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association.

Here’s a quick rundown of some of what’s in the proposed rule. Expect a second article in the coming days that outlines additional provisions related to the Quality Payment Program, which includes the Merit-based Incentive Payment System.

Another conversion factor cut — but not as severe as anticipated.
CMS proposes another decrease in the conversion factor, one of the elements used in calculating final payment amounts for various codes. This time around, the conversion factor is $32.7476, a 3.3% decrease from the $33.8872 conversion factor adopted in 2023. The change is far-reaching, affecting more than 27 specialties including physical therapy.

While still damaging, the cut was less than the anticipated 4.2% cut, which would’ve been similar to last year’s reduction. The reason, according to CMS, is that it reconsidered utilization estimates of a particular evaluation and management add-on code, which in turn allowed the agency to back off on cuts to the conversion factor. CMS must make the reductions to the conversion factor to offset the evaluation and management increases in order to maintain budget neutrality.

An exploration of potentially misvalued codes, with the possibility for increases.
In early 2023, APTA made the case to CMS that several codes frequently used by PTs are subject to a kind of double jeopardy that unfairly cut values. The association argued that, first, 19 codes that include therapeutic exercises, neuromuscular reeducation, gait training, and therapeutic activities were undervalued by the AMA Relative Value Scale Update Committee that sets payment rates typically adopted by CMS. Second, these codes simultaneously were subject to reductions associated with the Multiple Procedure Payment Reduction system. The association asserted that both devaluations are being made for the same ostensible reason — to account for a duplicative practice expense when multiple codes are used on the same day. APTA told CMS that discounting codes twice for the same rationale didn’t make sense.

CMS listened. In the proposed rule, CMS directs the AMA committee to re-review its earlier value recommendations. The list of affected codes can be found on Page 66 of the proposed rule. If this reconsideration is adopted in the final rule, APTA believes that the values of many of the codes on the list will be increased.

Consideration of moving to general supervision for PTAs in private practice, extension of virtual supervision through 2024, and relaxed requirements around PTAs doing RTM.
Could CMS be seeing the light when it comes to supervision of PTAs in private practice settings? In response to advocacy from APTA and other groups, the agency is asking for public comment on the possibility of moving away from direct supervision of PTAs and occupational therapy assistants in private practice — currently the only setting under Medicare in which 100% face-to-face supervision is required — in favor of general supervision. APTA and the American Occupational Therapy Association have made the shift to general supervision a top-level advocacy priority that even includes potential federal legislation.

In the proposed rule, CMS asks for feedback on safety concerns, potential limits on the types of services provided under general supervision, patient visits by the supervising PT or OT, and possible effects on hiring. APTA will provide detailed comments on these issues by the Sept. 11 deadline.

In more good news, the proposed rule also extends virtual supervision of PTAs and OTAs through the end of 2024. That flexibility was set to expire at the end of 2023, in conjunction with the end of the pandemic-related public health emergency.

The proposed rule also includes a potential win for decreased administrative burden around remote therapeutic monitoring, or RTM, when conducted by PTAs: CMS proposes a general supervision-only requirement for PTAs performing RTM, regardless of setting. That change would take effect in 2024.

Adoption of new caregiver training codes.
In another win for APTA, CMS proposes the adoption of codes that would allow PTs, OTs, speech-language pathologists, and other providers to bill for providing training to caregivers of patients living with a functional deficit. The addition to the fee schedule is CMS’ acknowledgement of the advocacy gains made by APTA, AOTA, and ASHA when the groups successfully lobbied the AMA Current Procedural Terminology Editorial Panel to accept the codes for use beginning in 2024.

Confirmation that telehealth can continue through 2024.
In the proposed rule, CMS follows through on its assurances that it would adopt a Dec. 31, 2024, date for the end of telehealth allowances for PTs and PTAs under Medicare. The end date brings Medicare policy in line with requirements of the Consolidated Appropriations Act of 2023. In addition, the fee schedule avoids an earlier CMS error — the exclusion of institutional settings from the list of settings allowed to provide PT services via telehealth. CMS corrected that mistake after it was pointed out by APTA earlier this year, and extended telehealth to all outpatient settings through 2023. That allowance continues through the end of 2024 in the proposed rule.

The larger issue — including PTs and PTAs among providers permanently empowered to provide telehealth services under Medicare — is the target of another significant advocacy push from APTA and other supporters. CMS says that it doesn’t have the statutory authority to change its list of approved telehealth providers to include PTs. Bipartisan legislation has been introduced in the U.S. House of Representatives that would do exactly that and more. Until that happens, the agency says it will avoid making telehealth codes for PT services permanent.

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The Centers for Medicare and Medicaid Services (CMS) has clarified that outpatient therapists can continue to bill Medicare Part B for telehealth services across a range of facilities, including home health, as it did during the pandemic. 

The update represents a positive development for hospital-based therapists. As the end of the PHE loomed, it appeared that these therapists could not continue to provide services through telehealth. Earlier this month, CMS reversed course and said the therapists could continue to provide telehealth services. CMS further clarified the use of Medicare Part B outpatient therapy services for other settings, including home health agencies, in a FAQ sheet on May 19. 

Katie Wehri, director of home care and hospice regulatory affairs for the National Association for Home Care & Hospice, told McKnight’s Home Care Daily Pulse the decision to allow the use of telehealth for Medicare Part B outpatient therapy services makes sense. 

“We support using telehealth when appropriate, so in that sense, we think it’s great,” she said. 

Kate Gilliard, the American Physical Therapy Association’s (APTA) director of health policy and payment, said in a statement that APTA was “extremely happy” with CMS’s decision to continue telehealth coverage.

She also, however, raised concerns to McKnight’s Home Care Daily Pulse over when the extension will end.

“They [CMS] did put an end date for hospital outpatient departments at the end of 2023, but we’re very uncertain where they are getting that date from,” she said, in reference to their decision earlier this month to extend telehealth coverage for hospital-based facilities.

Congress last year passed the Consolidated Appropriations Act of 2023, which directed CMS to extend access to therapy delivered via telehealth through Dec. 31, 2024. Gilliard said APTA would like to see CMS respect that date.

“At the bare minimum, right now, we’d like to see the Consolidated Appropriations Act enforced and implemented,” she said.

She also said that APTA, along with the American Speech-Language-Hearing Association and the American Occupational Therapy Association, will continue to meet with CMS to discuss the future of telehealth coverage. She also said they will meet with providers to discuss the legal implications of CMS’s decision.

“We’ll want to address CMS and other institutional providers, like home health agencies, to make sure that we know what people can and can’t do and when they can and can’t do it,” she said. 

Still, Gilliard sees the decision as progress and is happy providers have more clarity on their telehealth situations.

“The worst part about this whole thing was the uncertainty. People for a few weeks just plum didn’t know what was legal or not,” she said.

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