All These Doggone Changes: 2022 Proposed Rule Overview for PTs, OTs, and SLPs

It’s time to shake things up a bit! Or at least, CMS says it’s time to shake things up a bit. Every year, roughly six months in, the Centers for Medicare and Medicaid Services releases its proposed regulatory and payment changes for the following year. True to form, CMS released its 2022 proposed rule this week, and it’s chock full of information that rehab therapists need to know. But rather than asking y’all to read through all 1700 doggone pages of proposals, we read through it for you. And to make this info even more approachable, we’ve wrapped it up in lingo that’s a little friendlier than normal—and dare we say cuter? Lingo that has more bark than bite, if you will. (Yeah, yeah, okay. It’s just a bunch of dog puns.) 

It’s time to German Shepherd in the PTA and OTA payment differential. 

The PTA and OTA payment differential has been cropping up in the proposed and final rules for a few years now—and it’s finally time for it to take effect. Don’t remember the details of the PTA and OTA payment differential? No worries—here’s a quick refresher: 

• When Congress repealed the therapy cap back in 2018, it suggested implementing payment cuts to services provided by PTAs and OTAs to preserve budget neutrality.
• In the 2019 final rule, CMS moved forward with a plan to implement a PTA/OTA payment differential. 
  • Speaking broadly, CMS planned to pay 15% less for services provided in part or in full by a PTA or an OTA.
•  To execute this differential, CMS created the CQ modifier for PTAs and the CO modifier for OTAs, and requested that the industry begin using them in 2020.
  • CMS planned to activate the differential in 2022. 

And that brings us to the 2022 proposed rule. 

CMS clarified that the differential is slightly less severe than it first appears. 

Beginning January 1, 2022, the CQ and CO modifiers will trigger a 15% payment reduction to services provided by therapy assistants. However, CMS clarified that rehab therapists will only see a 12% drop to payments made for services tagged with CQ or CO. Here’s why.

CMS pays for 80% of allowed charges, while Medicare beneficiaries pay the remaining 20% as a copayment. The 15% payment differential applies only to the allowed charges that Medicare pays, which means that—once you do some math—the assistant payment differential is actually only 12%, and Medicare will still ultimately pay 88% of services provided by PTAs and OTAs. 

The rules for applying the CQ and CO modifiers may change a little bit. 

Due to some concerned comments about the application of the CQ and CO modifiers, CMS is proposing a slight (and beneficial) change to the application process. Here are the rules as they currently stand: 

• When a PTA or OTA provides more than 10% of a service (whether that’s an untimed unit or a 15-minute unit), then you must apply a CQ or CO modifier, respectively.   
• When a PTA or OTA provides a service in tandem with a PT or OT, these services are considered “provided by the therapist” and the CQ and CO modifiers do not apply.
• If a PTA or OTA provides 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 to two different claim lines and apply CQ or CO only to the applicable units.  

After receiving comments from concerned therapists, CMS is proposing a final addition to their rules for applying the CQ and CO modifier. It reads that when a PT or OT “provides enough minutes of the service on their own to bill for the last unit of a timed service,” disregard any time provided by the PTA and OTA and do not apply the CQ or CO modifier.

So for instance, if a PT provides 11 minutes of 97110 and a PTA also provides 11 minutes of 97110, bill one unit of 97110 without the CQ modifier. (Want more help with these modifiers? Keep your eyes on the blog—we plan to write more about this topic!)

No need to be Terrier-fied—but reimbursement rates may fall a little bit.

CMS proposed cutting the conversion factor (i.e., the number that determines all CPT code payments) from $34.8931 to $33.5848. What does that mean for rehab therapists? Well, CMS estimates that this will result in a 2% cut to physical and occupational therapy payments. Speech therapists weren’t included on the estimated impact table—though audiologists were, and will see an estimated 1% cut to their Medicare payments. 

Feeling the squeeze from reimbursement cuts? Let WebPT help you maximize your billing and get every dollar you deserve.

CMS made a Chihuahua-sized fix to OT evaluation RVUs.

In the 2021 final rule, CMS adjusted the practice expense value of RVUs for OT evaluation codes (i.e., it fiddled around with how it calculated payments for those codes). Ultimately, these changes ensured that the practice expense portion of payment for all three OT evaluation codes was the same. However, that created some complications: “By forcing CPT codes 97165-97167 to have the same indirect PE allocation, the indirect PE values for these codes no longer relied on the claims data, which ended up affecting the indirect practice cost index for the wider occupational therapy specialty. Because CPT codes 97165-97167 are high volume services, this resulted in a lower indirect practice cost index for the occupational therapy specialty and a smaller allocation of indirect PE for CY 2021 than initially proposed.”

CMS is proposing to fix this snafu by assigning all claims data associated with OT evaluation codes to the occupational therapy specialty. “This should ensure that CPT codes 97165-97167 would always receive the same indirect PE allocation as well as preventing any fluctuations to the indirect practice cost index for the wider occupational therapy specialty.”

This change wouldn’t have a direct effect on the OT billing process—though it would hopefully bring OT eval payments up to par. 

Don’t shake the pom-Pomeranians: Rehab therapy services will not be added to the permanent list of telehealth services. 

As a reminder, CMS doesn’t have the authority to make PTs, OTs, or SLPs eligible telehealth providers. Only an act of Congress can change that. As such, there are no plans in the 2022 proposed rule to extend telehealth privileges for rehab therapists beyond the active public health emergency (PHE). 

Beyond that, CMS specifically clarified that it would not add the following rehab therapy services to the permanent list of telehealth services (meaning that physicians won’t be able to provide them post-PHE either): 

In explaining its justification for this denial, CMS said many of these services “are therapeutic in nature and in many instances involve direct physical contact between the practitioner and the patient.” Beyond that, CMS also said “we concluded that it did not provide sufficient detail to determine whether all of the necessary elements of the service could be furnished remotely, and whether the objective functional outcomes of ADL and IADL for the telehealth patients were similar to those of patients receiving the services in person.”

However, CMS didn’t completely slam the door in rehab therapists’ faces. In fact, it invited PTs, OTs, and SLPs to collect and share data proving that telehealth therapy is a viable treatment option: “We continue to encourage commenters to supply sufficient data for us to be able to see all measurements/parameters performed, so that we may evaluate all outcomes.”

Hounding (i.e., supervising) visits may be different in the future. 

For the duration of the PHE, CMS changed 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.” CMS is seeking comments as to whether or not it should make this change permanent.  

CMS is seeking Pointers about RPM and RTM codes.

In the 2021 final rule, CMS clarified that RPM codes (99453, 99454 and 99457) are considered evaluation and management (E/M) codes, and therefore cannot be billed by rehab therapists. However, CMS recognizes the value in allowing therapists to bill codes like these—so it’s proposing to create sister RTM codes (remote therapeutic monitoring) that are accessible to non-physician and non-NPP clinicians. 

• 989X4: “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”
• 989X5: “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”
• 989X1: “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”
• 989X2: “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”
• 989X3: “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”

CMS is caught in a pickle, though. Because it doesn’t want to classify these new codes as E/M services, it cannot designate them as care management services. As such, CMS is struggling to classify these codes and is seeking feedback. 

MIPS is Border-Collie-line the same. 

Since we’ve started following the MIPS program in 2018, it hasn’t experienced too many major changes—and it’s looking as though 2022 will be no different. The low-volume threshold criteria isn’t changing—though CMS has proposed allowing subgroups to determine their eligibility at the group level. (For context, this mostly applies to multi-specialty practices wherein members of the larger practice group may split into subgroups to report on measures that better apply to them.) Additionally, CMS proposes to continue reweighting the promoting interoperability category for all rehab therapists and audiologists. 

CMS is seeking comments about some MIPS Value Pathways. 

In response to complaints that the MIPS program was overly complex, CMS concocted MIPS Value Pathways (MVPs). MVPs essentially connect measures and activities across the different reporting categories that align with specific specialties or conditions. While MVPs won’t take effect until 2023, CMS is still seeking comments about them—and there’s exactly one MVP that applies to rehab therapists: Improving Care for Lower Extremity Joint Repair. Check it out here. 

Some quality measures and improvement activities may go away. 

While there were no changes to the SLP specialty measure set, CMS did propose a change to the PT/OT specialty measure set—namely removing measure 154: Falls: Risk Assessment. It has also proposed removing measure 050: Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older. While measure 050 is not currently in the PT/OT specialty measure set, CMS said that if it kept the measure around, “We would update the denominator eligible encounters to add coding for Physical Therapy MIPS eligible clinician type and add the measure to the Physical Therapy/Occupational Therapy specialty measure set.”

Additionally, CMS proposed to remove some improvement activities—though of those, rehab therapists most often report the following three:

• 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

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Remember, these changes are not finalized. If you would like to voice your opinion to CMS about any of these proposals, submit a comment to the uploaded document in the Federal Register by Monday, September 13, 2021.