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A Whale of a Time: Diving Into the 2022 Final Rule

Dive into the changes in the 2022 final rule that most affect PTs, OTs, and SLPs.

Melissa Hughes
5 min read
November 5, 2021
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Earlier this week, the Centers for Medicare and Medicaid Services (CMS) dropped the 2022 final rule—an oceanic-sized document that tells every healthcare provider who bills Part B what regulations and payment protocols are changing in the coming year. Diving into the rule is a daunting task, which is why WebPTers take the first plunge and tell you what we find! This year, PTs, OTs, and SLPs are facing a wide array of regulation tweaks (both good and bad). Let’s sea what’s in store!

Note: If you want to dive more in depth about any of the changes listed in this blog, follow the links! They’ll take you to the exact page of the final rule that I’m sourcing for that specific information. 

CMS sealed the deal on the PTA and OTA payment differential.

The PTA and OTA payment differential has been a contentious subject since it was first introduced, but with the approach of 2022, it’s time for the reduction to finally take effect. Here’s how the legislation shook out—and how it will affect PT and OT billing practices.  

Background Information

To help offset the costs of removing the therapy cap back in 2018, CMS is implementing a PTA and OTA payment differential: a 15% reduction to services provided in part—or in full—by a therapy assistant. To help facilitate this differential, CMS created two payment modifiers to signal when a PTA or OTA contributed to treatment (CQ and CO, respectively). While PTs and OTs began using these modifiers in 2020, the differential was always intended to take effect in 2022—and it still will. 

Modifier Application

There’s a lot to chew on in this section of the final rule, but the basics of the CQ and CO modifiers boil down to this: 

  • When a PTA or OTA independently provides at least 10% of a service (whether that’s a timed or untimed unit), you must apply a CQ or CO modifier, respectively. 
  • When a therapy assistant provides a service in tandem with a PT or OT, those minutes do not count toward the 10% de minimis benchmark. 
  • If a therapy assistant furnishes more than 10% of one unit of a service, “but does not contribute to other units of that same service, then you can split the service into two different claim lines and apply CQ or CO only to the applicable units.”
  • The de minimis rule (i.e., the 10% benchmark) will not apply “when the OT/PT provides more than the midpoint of a 15-minute timed code, that is, 8 or more minutes, regardless of any minutes for the same service furnished by the OTA or PTA.”

Documentation Requirements

As a reminder, there are no additional documentation requirements for the CQ and CO modifiers. CMS previously ruled that “we would expect the documentation in the medical record to be sufficient to know whether a specific service was furnished independently by a therapist or a therapist assistant, or was furnished ‘in part’ by a therapist assistant, in sufficient detail to permit the determination of whether the 10 percent standard was exceeded.”

How CQ and CO will Affect Payments

CMS once again clarified that the therapy assistant differential will actually translate to a 12% reduction in payments due to the relationship between allowed charges and Medicare copayments. CMS also clarified the order in which deductions occur to payments. In a situation where MPPR and PTA/OTA modifiers apply, MPPR is applied first, followed by the 20% coinsurance deductible, the 15% assistant differential, and the 2% sequestration reduction (when applicable). 

(These modifiers have shaped up to be a total doozy! Be sure to watch the WebPT blog for more information about CQ and CO and examples of how to use them.)

CMS took a swordfish to reimbursement rates—again.  

In a move to preserve previously mandated budget neutrality, CMS has officially cut the 2022 conversion factor from $34.8931 to $33.5983—resulting in a 3.7% decrease to payments overall. 

No need to hide in your turtle shell: CMS tweaked OT evaluation RVUs only slightly. 

CMS is moving forward with its proposal to fix how OT evaluation RVUs (and ultimately payments) are calculated. Moving forward, CMS is “assigning all claims data associated with CPT codes 97165-97167 to the occupational therapy specialty. This should ensure that CPT codes 97165-97167 will always receive the same indirect PE allocation, as well as prevent any fluctuations to the indirect practice cost index for the wider occupational therapy specialty.”

In other words, OTs will be paid fairly for their evaluation services—without any billing changes on their end. 

CMS krilled PT, OT, and SLP telehealth hopes—for now. 

As indicated in the proposed rule, CMS has reiterated that PTs, OTs, and SLPs will not be able to provide telehealth after the conclusion of the public health emergency (PHE). This is because: 

  1. CMS does not have the legal authority to make PTs, OTs, and SLPs eligible telehealth providers (only Congress can do that); and 
  2. CMS feels it has yet to see evidence proving that virtual therapy provides “clinical benefit” to Medicare beneficiaries. 

As such, CMS is not adding the following CPT codes to the permanent telehealth list, and they must be provided in person upon the conclusion of the PHE: 

  • 90901
  • 90912
  • 90913
  • 97110
  • 97112
  • 97116
  • 97150
  • 97161
  • 97162
  • 97163
  • 97164
  • 97530
  • 97535
  • 97537
  • 97542
  • 97750
  • 97755
  • 97763
  • 98960
  • 98961
  • 98962
  • 92607
  • 92608
  • 92609

As a reminder, CMS is open to adding these codes to the permanent telehealth list—provided that they meet the criteria of a category 2 service (which you can learn more about here). The agency urges therapists to collect data proving that teletherapy belongs in that category, alongside the reminder that “We do not believe ADLs and IADLS alone are sufficient to demonstrate clinical benefit to a Medicare beneficiary.”

Telehealth Payment Parity 

While discussing telehealth privileges, CMS also addressed some comments asking about telehealth payments. Its response was illuminating: 

“With regard to the comment requesting Medicare telehealth payment at the non-facility versus facility rate, we refer readers to discussion of this issue in the CY 2017 PFS final rule (81 FR 80199 – 80201). Payment for telehealth services using the facility PE RVUs is consistent with our belief that the direct practice expense costs are generally incurred at the originating site where the beneficiary is located, and not by the distant site practitioner.”

In other words, CMS believes that telehealth reduces overall practice expenses—a significant component of payment calculations—and, therefore, should be paid at a lower rate than in-person services. 

Continue to keep a supervising walleye on your assistants.  

In the proposed rule, CMS considered changing the definition of direct supervision “to allow the supervising professional to be immediately available through virtual presence using real-time audio/video technology, instead of requiring their physical presence.” But commenters (specifically MedPAC) found the proposal to be a little problematic, stating that:

  • “Allowing clinicians to supervise ‘incident-to’ services virtually could pose a safety risk to beneficiaries;”
  • “Virtual supervision could potentially enable a clinician to supervise many individuals at multiple locations at the same time,” thus jeopardizing their ability to address urgent needs; and 
  • “This scenario could also lead to higher spending by allowing clinicians to bill for more “incident-to” services during a single day.”

Ultimately, CMS is kicking the can down the line and abstaining from making any final judgments about supervision. CMS “Will consider addressing the issues raised by these comments in future rules or guidance, as appropriate.”

You don’t have to be a shark to sink your teeth into the RPM and RTM code changes.  

In the 2021 final rule, CMS clarified that rehab therapists cannot bill remote patient monitoring (RPM) codes (99453, 99454, and 99457) because they are evaluation and management services. That said, it recognized the value of allowing therapists to provide these services (or similar services), and thus, proposed to create new remote therapeutic monitoring (RTM) codes that are billable by rehab therapists. 

CMS received a lot of mixed feedback about this proposal, with some commenters offering full and complete support for these new codes and others raising concerns about incident-to billing and supervision requirements. At the end of the day, CMS has chosen to finalize the following list of codes because “Despite our concerns about the construction of the codes, we believe the services described by the codes are important to beneficiaries.” Here’s what rehab therapists will be working with

  • 98980: “Remote therapeutic monitoring treatment management services, physician/ other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes.”
  • 98981: “Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes.”
  • 98975: “Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment).”
  • 98976: “Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days).”
  • 98977: “Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days).”

But before you bill these codes, there are a few things to note about them: 

  • These five codes are officially “sometimes therapy” codes.
  • The device codes 98976 and 98977 “are not subject to the de minimis standard” that dictates therapy assistant payments.  
  • CPT code 98975, however, “is subject to the de minimis policy” that dictates therapy assistant payments. 

Be warned: Considering the language it used in this section, CMS will likely revisit the structure of these codes in a future rule. 

There’s a shrimpy increase to the therapy threshold.

The therapy threshold (i.e., the dollar amount therapists can bill for each patient before the KX modifier comes into play) is getting a minor increase in 2022. CMS is raising the threshold to a combined $2,150 for physical therapy and speech therapy and to $2,150 for occupational therapy. 

CMS made porpoiseful changes to MIPS.

The 2022 final rule also outlined some changes to the Merit-based Incentive Payment System (MIPS) program—though the changes that concern rehab therapists aren’t much to sweat about. First, the low-volume threshold is remaining the same, though CMS is giving multi-specialty practices (think POPTs) some flexibility by allowing them to create subgroups. These subgroups will be able to report measures that are specific to their specialty instead of requiring all members of the multi-specialty group to report the same measures.

CMS will also continue to reweight the promoting interoperability and cost categories for PTs, OTs, and SLPs—meaning rehab therapy MIPS participants will only need to worry about the quality and improvement activities categories. 

MIPS Value Pathways 

In the proposed rule, CMS asked for comments about MIPS Value Pathways (a.k.a. MVPs): an initiative aimed to reduce the burden of reporting by connecting quality measures and improvement activities that align with specific specialties or conditions. After receiving a heap of comments, CMS has opted to make no immediate changes to MVPs—but will “continue a dialogue with stakeholders” and consider this feedback in future rules. 

That said, CMS did clarify that, while MVPs will at first be optional to report, they may become mandatory functions of MIPS by 2028. 

Quality Measures and Improvement Activities

This year, there will be no changes to the SLP specialty measure set. The PT/OT specialty measure set, on the other hand, will see some changes. CMS has added one quality measure to the PT/OT specialty measure set: 

  • 050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older

The agency has also removed one measure from the PT/OT specialty measure set: 

  • 154: Falls: Risk Assessment

And while it does not technically belong to either specialty measure set, moving forward, PTs, OTs, and SLPs will have the option to report measure 293: Parkinson’s Disease: Rehabilitative Therapy Options.

Finally, CMS is deleting some “duplicative” improvement activities. These are the deleted activities most often reported by rehab therapists: 

  • IA_BE_13: Regularly assess the patient experience of care through surveys, advisory councils and/or other mechanisms.
  • IA_BE_20: Implementation of condition-specific chronic disease self-management support programs.
  • IA_BE_21: Improved practices that disseminate appropriate self-management materials.

And that sums up the major changes in the 2022 final rule that PTs, OTs, and SLPs need to be aware of—for now! For a more detailed explanation on these changes, be sure to attend our upcoming webinar on Tuesday, December 14, at 9:00 AM PST. See you then!


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