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8% Physical Therapy Cuts Questioned By Lawmakers

In our November 6th FutureFocus e-newsletter, we wrote on the proposed 8% cut to therapy payments. Lawmakers are speaking out asking CMS for more details.

Nearly 100 U.S. lawmakers last week submitted a letter to Seema Verma, administrator of the Centers for Medicare & Medicaid Services, concerned about the proposal that cuts 8% in Medicare payment for physical and occupational therapy services.

“Concerns about whether the implementation of certain aspects of this rule will reduce access to health services has been raised to us,” they wrote. “To better respond to these concerns, we are requesting additional information regarding the process by which CMS reached the decision to reduce the reimbursement for services furnished by certain providers in 2021 to accommodate for the increases to the values of the office/outpatient [E/M] codes.”

Background

The Bipartisan Budget Act of 2018 requires payment for services furnished in whole or in part by a therapy assistant at 85 percent of the applicable Part B payment amount for the service effective January 1, 2022. In order to implement the payment reduction, the law requires a new modifier by January 1, 2019 be established, and for CMS to detail plans to accomplish this in the final rule.

CMS is finalizing our proposal to establish two new modifiers – one for Physical Therapy Assistants (PTA) and another for Occupational Therapy Assistants (OTA) – when services are furnished in whole, or in part by a PTA or OTA. However, CMS is finalizing the new modifiers as “payment” rather than as “therapy” modifiers, based on comments from stakeholders.

These will be used alongside of the current PT and OT modifiers, instead of replacing them, which retains the use of the three existing therapy modifiers to report all PT, OT, and Speech Language Pathology services, that have been used since 1998 to track outpatient therapy services that were subject to the therapy caps.

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. The new therapy modifiers for services furnished by PTAs and OTAs are not required on claims until January 1, 2020.

Lawmakers Requesting More Information

The letter from lawmakers is asking CMS to explain the agency’s methodology and the data used to calculate the estimated impact the coding change would have on each specialty. It also asks the agency what additional information it would consider before preparing the final 2021 physician fee schedule. There is also concern how the changes may impact beneficiary access to specialty services.

Lawmakers asked for a response no later than Feb. 21.