Blog Post

CMS’s Final Bow: The 2019 Final Rule

FLR is out, and MIPS is in. Here's everything else you need to know about CMS's 2019 final rule. Get your practice ahead of the curve.

Melissa Hughes
5 min read
November 5, 2018
image representing cms’s final bow: the 2019 final rule
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Last week, the Centers for Medicare and Medicaid Services (CMS) published its 2019 final rule. Clocking in at just over 2,300 pages, the final rule isn't exactly a light read—especially because the legal lingo can be harder to interpret than Shakespearean verse. Luckily, we have the script—with all its twists and turns—decoded and ready for you to review. Here's the synopsis:

Out, Out FLR!

CMS took a cue from Lady Macbeth and washed its hands of all functional limitation reporting (FLR) requirements. That's right, FLR is dead and gone; beginning in 2019, PTs, OTs, and SLPs will no longer have to select and report FLR codes and modifiers (e.g., HCPCS codes G8978 through G8999 and G9158 through G9186, and severity modifiers CH through CN) in order to receive reimbursement.

Although CMS originally proposed removing the 42 non-payable HCPCS codes associated with FLR, it decided to keep them around for another year to allow providers and insurers time to update their billing systems and policies (and thus, avoid claim rejections due to inadvertent non-payable code submission).

Because non-payable HCPCS codes are sticking around for another year, MIPS-eligible PTs, OTs, and SLPs may use six of the remaining G-codes for MIPS quality reporting in 2019.

What MIPS May Come

Speaking of MIPS, it's official: PTs, OTs, and qualified SLPs will be included in the Merit-Based Incentive Payment System (MIPS) program in 2019. But MIPS participation is no Hamlet-level tragedy. (And if we're being honest, it would be pretty tough to top that whole mess.) After all, MIPS allows participants the opportunity—likely their only opportunity—to increase Medicare reimbursements over the next few years.

PTs, OTs, and SLPs Will Participate in Two MIPS Categories

The MIPS program requires participants to submit information across four categories:

  1. Quality,
  2. Improvement Activities,
  3. Cost, and
  4. Promoting Interoperability.

CMS then scores the categories, and each participant's overall score determines the payment adjustment that participant will receive, with adjustments ranging between -7% and +7%.

Because 2019 is the first year PTs, OTs, and SLPs are eligible to participate in MIPS, they will only be scored in the Quality and Improvement Activities categories.

There's a New Addition to the Low-Volume Threshold Criteria

CMS also tinkered with the low-volume thresholds for the 2019 performance year. Though the two criteria from the previous year will stay the same, there is a new addition to the pack.

In 2019, if one of the following statements holds true for a MIPS-eligible clinician or group, they will not be required to participate in MIPS:

  1. The provider or group did not charge more than $90,000 for covered professional services.
  2. The provider or group treated 200 or fewer Part B-enrolled individuals.
  3. The provider or group provided 200 or fewer professional services to Part B-enrolled individuals.

Clinicians and groups have the opportunity to opt into MIPS if they only meet one or two of the three low-volume thresholds. Those who meet all three criteria, however, are not able to opt in.

If you want to learn more about MIPS—including whether you'll be required to participate and, if not, whether you should participate on a voluntary basis—then grab your buddy Yorick and sign up for our free MIPS webinar on December 12, 2018.

What's in a Name—That Which We Call KX Modifier

Therapy cap, oh therapy cap. Wherefore art thou limits, therapy cap? Not where they were last year, apparently.

There's Still a Soft Cap—But the Threshold Amount is Higher

Earlier this year, CMS officially repealed the hard cap on therapy services and replaced it with a threshold amount (often called the “soft cap”) beyond which therapists must apply the KX modifier in order to receive payment for medically necessary services. (So, although the repeal was a hard-won victory on the advocacy front, for all intents and purposes, therapists' claims workflow hasn't really changed.)

With this rule, CMS increased the KX modifier threshold by 1.5% and rounded up to give rehab therapists a shiny new soft cap of $2,040 for PT and SLP services combined and $2,040 for OT services. The targeted medical review (MR) threshold will remain at $3,000, and, as has always been the case, “some, but not all claims exceeding the MR threshold are subject to review.”

The KX Modifier is Here to Stay

The general rules for KX modifier use will stay the same, though. (Need a refresher on when to use the KX modifier? Check out this blog post.)

Et Tu, CMS? New Modifiers for PTAs and OTAs

The 2019 Final Rule also slashed future PTA and OTA reimbursement rates. (Think Julius Caesar levels of slashing.) Beginning in 2022, when claims contain one of the new, assistant-dependant payment modifiers, Medicare will only reimburse 85% of the cost of the provided service.

Definitions for the Original Therapy Modifiers Will Stay the Same

At the end of the day, CMS decided to leave the descriptions for the main therapy modifiers (GP, GO, and GN) untouched due to some critical feedback the agency received during the final rule commenting period. Commenters were concerned that the proposed changes to the therapy modifier set—and the individual code definitions—would increase their documentation burden and create billing confusion. So, they suggested that CMS implement unique PTA and OTA payment modifiers instead.

The final rule authors decided commenters had a fair point, stating, “We also agree that adding the new therapy assistant modifiers to the same claim line of service alongside the existing GP and GO modifiers will prevent undue burden for physical therapists and occupational therapists, as only PTAs and OTAs will add the new modifiers to the claim line of service.”

Thus, CMS finalized the following payment modifiers to denote when PTAs and OTAs were involved in furnishing care:

  1. CQ modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant
  2. CO modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant

There Was Strong Resistance to the Proposed Definition of “In Part”

Following the release of the proposed rule earlier this year, there was much ado about how CMS would define “in part.” CMS initially proposed that “in part” should mean “any minute of the outpatient therapy service that is therapeutic in nature.” Under that definition, if a PTA or OTA were in any way involved in the treatment of a particular patient, then the practice would need to bill with the payment reduction modifier.

CMS received significant blowback about this proposal during the commentary period, with one commenter even stating that “applying the modifier when any minute of outpatient therapy is delivered by a therapy assistant has serious implications for beneficiary access to care.”

Many commenters proposed alternative, less restrictive definitions for “in part,” while others suggested that CMS designate certain exceptions to the application of the proposed definition (i.e., situations in which the “in part” caveat would not apply).

“In-Part” PTA and OTA Participation Means at Least 10% of Care

Ultimately, CMS elected to define “in part” using a “de minimis standard.” Specifically, if a PTA or OTA provides more than 10% of a therapy service, the new payment modifiers must be applied, and Medicare will only pay 85% of the service cost.

Here's the example provided in the final rule:

If this 10 percent de minimis standard is applied to an untimed service, for example to a therapy evaluation for which the typical time is 45 minutes, the PTA or OTA could furnish up to 4.5 minutes of the service before the modifier and discounted payment rate would apply.

It's important to note that the new modifiers should not be applied when a PTA or OTA performs a service that's unrelated to his or her qualifications (e.g., administrative tasks, scheduling, greeting/gowning, or preparing/cleaning rooms).

Reimbursement Reductions Will Take Effect in 2022

As for timing, while the 15% payment reduction will not go into effect until January 1, 2022, providers must begin submitting the new PTA and OTA modifiers on January 1, 2020. Additionally, despite comments requesting “that CMS exempt therapy services furnished in rural areas, health professional shortage areas (HPSAs), and medically underserved areas (MUAs) from application of the reduced payment rate when a therapy assistant is involved,” CMS does not currently plan to waive the reimbursement reduction for providers in those areas. However, CMS does plan to “monitor for potential access issues and consider how to address them should they arise.”

Much Ado About CPT Codes

CMS updated the Physician Self-Referral List of CPT/HCPCS Codes, and there are two deletions relevant to rehab therapy. Sigh no more, because the following codes are no longer included on this list:

  • 64550: Appl surface neurostimulator
  • 96111: Developmental testing

While the lines pertaining to rehab therapists were few and far between, those that made the cut certainly were scene-stealers. Have questions about what this means for you and your practice in 2019 and beyond? Leave 'em for us in the comment section below, and keep your eyes peeled for more updates. And as my good friend Will once said, “This above all: to rehab therapy, be true.”

Well, maybe he didn't say exactly that.


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