October Founder Letter: Avoiding Potential Billing and Compliance Scares

We may be well into the age of the superhero movie (and TV show, and video game, and everything else), but who knew you had to be the Flash to keep up with all the changes in healthcare compliance? The current rate of change in therapy-specific updates is the most I’ve seen in my 40-plus years in PT and probably nearly impossible for most clinicians to keep up with while still balancing every other responsibility. That’s why Heidi and I host our annual billing Q&A webinar, the latest edition of which is on October 25; you can register to attend at the link above. 

However, with so much happening, we thought offering an early look at some of the key updates we’ll discuss during our session would be useful. Without further ado, let’s look at some of the most significant changes.

We’re getting more specific ICD-10 codes for Parkinson’s Disease. 

As of October 1, ICD-10 2024 has gone into effect. The most significant coding change in therapy practices is the expansion of diagnoses for Parkinson’s Disease (PD) diagnostic set. The PD code (G20) is being deleted and replaced with five new Parkinson’s codes that are more specific:

• G20A1 PD without dyskinesia, without mention of fluctuations,
• G2A2 PD without dyskinesia, with fluctuations,
• G20B1 PD with dyskinesia, without mention of fluctuations,
• G20B2 PD with dyskinesia, with fluctuations, and
• G20C Parkinsonism, unspecified.
  

If you haven’t already, update your ICD-10 book or application to the 2024 version and your Parkinson’s patients’ diagnoses.

UnitedHealthcare is getting rid of some requirements—and adding new ones. 

In August, United Healthcare (UHC) announced a policy change to require a physician's signature on a therapy plan of care (POC). Fortunately, after significant advocacy efforts, they have walked that back, and it will not be implemented as planned. However, UHC simultaneously announced that start and stop times for treatment will need to be included in the therapy documentation. This change did go into effect, so be sure to include the start/stop times of your visits with UHC/OPTUM.

Aetna is updating its rules for assistants.

Aetna is the next large insurance payer to implement the CMS Assistant de minimus rules and require the CO and CQ modifiers for assistant services. This applies when an assistant delivers 10% or more of a service and results in a 15% reduction to their fee schedule. It is interesting that Aetna, which pays about 25% less than Medicare, wants to discount its already value-reduced payments deeply.

We’re finally getting some prior authorization reform. 

Thanks to significant coverage by the healthcare media on the payer abuses associated with prior authorization programs, we are finally seeing some initial changes in payers rethinking their programs.

• UHC has announced a reduction in prior authorization of services and DME items. These new policies will be going into effect over the fall and include the UHC Community plans, although the cutback is less for those plans than for the other programs.
• Aetna and BCBS of Michigan have also announced programs to be implemented throughout the fall to reduce requirements for prior authorization for therapy services.

Along those same lines, a majority of U.S. states are considering some form of legislation to force payers to rightsize the time-wasting, care-delaying payer practice of prior authorization. In total, nearly 90 prior-authorization reform bills have been considered in this legislative session in 30 states, with more than a dozen still on the table for potential passage.

The biggest potential legislative victory is the news that the powerful House Ways and Means Committee has advanced provisions that would help bring badly-needed reforms to the prior authorization process within Medicare Advantage. The provisions passed last week track closely with the Improving Seniors’ Timely Access to Care Act. That bipartisan legislation was introduced by Reps. Suzan DelBene, D-Wash., Mike Kelly, R-Pa., Ami Bera, MD, D-Calif., and Larry Bucshon, MD, R-Ind. and unanimously passed the House in mid-September. 

Among other things, this law will:

• Establish an electronic prior authorization process.
• Require the Department of Health and Human Services (HHS) to establish a process for real-time decisions for items and services that are routinely approved. 
• Improve transparency by requiring Medicare Advantage plans to report to CMS on the extent of their prior authorization use and the rate of approvals or denials. 
• Encourage plans to adopt prior authorization programs that adhere to evidence-based medical guidelines in consultation with physicians.

The proposed rule is adding new codes—and clarifying guidance around existing ones. 

The proposed rule is always hotly anticipated, and this year’s release from the Center for Medicare and Medicaid Services (CMS) is no exception. Here’s some of what we can expect to see in the 2024 Medicare Physician Fee Schedule Final Rule when it’s published to the Federal Register in late October or early November:

• CMS is offering more guidance on remote therapeutic monitoring (RTM) codes.
• Potential clarifications will likely be issued for the RTM codes. In particular, the ability for the RTM codes to be billed in the same month as the Remote Physiologic Monitoring (RPM) codes.
• The issuance of an RTM-specific policy will allow PT and OT assistants to provide these services under general supervision.
• CMS might also clarify issues with billing monitoring codes 98980 and 98981 every calendar month versus billing device codes 98976, 98977, and 98978 every 30 days with the required 16 days of data collection.
• We can expect to see the finalization of Caregiver Training CPT codes and their values.
• CMS has suggested that they might be revaluing 19 therapy codes because of the undervaluing of staff expense part of these codes' Practice Relative Value Units (RVUs).‍
• Telehealth services access will be extended through 2024.
• Direct supervision for therapy assistants may be changed to general supervision from direct supervision. 

Once the final rule is published, be sure to look out for our blog recap and annual December webinar highlighting the rehab-specific changes for 2024.

More rehab therapists are recognizing their value. 

Let’s step away from the specifics of billing and compliance to look at the bigger picture. Regardless of the changes that payers have in store for later this year or next year, the fact remains that there is still considerable downward pressure on fee schedules and payments for therapy services. Some of these changes represent an easing of the administrative burden and costs put on the shoulders of providers, but if rehab therapists want to survive in the long term, practice models need to change and evolve to provide the competitive pay therapists want. 

Start reconsidering provider agreements and contracts that don’t work. 

One way to do that is to cancel the preferred provider agreements with payers who aren’t adequately paying you for your value. It’s a topic I discussed during a recent Billing and Compliance Bootcamp webinar, which I do monthly for WebPT Members. Simply put, if your payment per visit isn’t sufficiently greater than your cost per visit, you need to consider renegotiating that contract or going out of network with that payer. After all, you are providing substantial value to payers in lowering costs for a number of diagnoses—and if you’re not going to pound the table for your value, payers will be more than happy to keep paying you at reduced rates. 

The often unacknowledged and painful truth about the value perception problem therapists and practice owners struggle with is that we’re largely responsible for it; because of a fear of losing access to new patients, too many providers have signed contracts for services and payer agreements that undervalue our services. Practice owners who have gone out of network have shown us that fear is unfounded and that many consumers will pay for the value of our services. 

Others have shown that we don’t need to suffer through ever-increasing and uncompensated administrative burden and opted to become non-participating providers with Medicare. Granted, that might not be the right approach for all practices, but a thorough, honest review of our payer agreements will at least help you recognize those payers whose draconian valuation of therapy services are worthy of you taking action in the forms of going out of network—or terminating those agreements altogether.

We’re collecting more evidence of the value of PT.

Fortunately, we’re getting more evidence we can use with payers to demonstrate that value. One of the most exciting reads of the past month is the APTA’s policy document entitled “The Economic Value of Physical Therapy in the United States.” In it, the APTA lays out an approach to calculating the value of a physical therapist intervention in ways that go beyond comparing short-term costs. It also addresses eight common diagnoses we see in PT and provides compelling research and data to support the net benefit that PT can provide to those patients in real dollars. If you haven’t read it already, I strongly recommend that you take the time to review it; it will give you a different way to talk about our value with payers, referral sources, and policymakers.

I’ll wrap up by saying that I hope you’ll use this information to stay on top of your billing and coding practices and take to heart the bigger fight we have on hand to change payers’ perception of our value. Part of what we do at WebPT, beyond the software and services, is to offer education and thought leadership so that you have the tools you need to take action and earn what you’re worth.   

If you’ve got billing questions about what I’ve addressed here or anything else that’s puzzling you, be sure to attend our webinar as Heidi and I answer as many as possible in an hour. And for any questions left unanswered, we always post a follow-up Q&A post to the blog.