The new year may be a new frontier for most people, but for rehab therapists, CMS is setting the course for the future with the release of the final rule each fall. And while it’s been out for a few weeks at this point, that doesn't make it any easier to parse the 2,700-plus pages of dense copy. Fortunately, we brought in Heidi Jannenga and Rick Gawenda to break down what you need to know during a lively webinar that lasted close to two hours. (If you missed it live, you can catch up with this recording.)
However, not even Heidi and Rick can keep pace with the volume of questions that came in about the final rule, so we’ve gone on a spacewalk to collect the ones left floating and provided you with answers below—with an assist from Rick Gawenda in Mission Control.
Caregiver Training Services Codes
Can the caregiver codes be used in the acute care setting or other settings beyond outpatient clinics?“
In the acute care setting, you are not reimbursed via CPT codes, rather, by DRGs,” says Gawenda. “If a patient that is an inpatient is switched to outpatient status, then the caregiver training services CPT codes could be applicable.”
Is there a CPT code for caregiver training with the patient present?
The new set of caregiver (CG) training CPT codes specifies that training must take place without the patient present. As Jannenga noted in the webinar, if the treating therapist completes CG training with a patient present while performing a therapeutic activity (97530) or activities of daily living training (97535), then these would be instances where CG training is lumped into the patient’s direct treatment.
So we can bill a patient for training their caregiver without them present, but what kind of consent is needed from the patient for this to occur?
As CMS states in the final rule:
“We do not believe that the general consent to receive treatment would besufficient to make a patient aware of the unique circumstances under which CTS are furnished.For these same reasons, we continue to believe it is appropriate to require a specific consent forCTS. We are using the term “consent” as opposed to other recommended terms to remainconsistent across other codes with consent requirements across the PFS. In cases of anAlzheimer’s or dementia diagnosis, we encourage providers to obtain consent from the patient ortheir representative for CTS as early as possible in the diagnosis… We are finalizing, as proposed, that the patient's (or representative's) consent is required for the caregiver to receive CTS and that the consent must be documented in the patient’s medical record.”
Could this group code be used to teach a group of families how to position children to do specific exercises?
So long as the families being used in the group code (97552) have pediatric patients being treated (i.e., not to be confused with an informative class for marketing purposes) and these exercises are reflected as necessary to the plan of care, then yes.
Is it true that a specific reason is needed as to why training without the patient is required? If so, what are some of the reasons we could use?
“Yes, you need to document why you are doing caregiver training services with a caregiver(s) without the patient present. There could be many reasons why this may need to occur, such as the patient’s mental status, emotional status, agitation of the patient, and things of that nature,” Gawenda notes. Does caregiver training have to be scheduled? If not, do we document it as a patient visit to bill?“Caregiver training services must be provided face-to-face with the caregiver(s), so in my opinion, you could schedule when the training will occur, but it’s not required that it’s scheduled in advance,” Gawenda states. “Caregiver training services do not count as a patient visit towards the progress report period.”
Is the caregiver code applied to the patient's deductible and threshold?
The caregiver training services (CTS) CPT codes are considered “sometimes therapy” CPT codes. This means the allowed amount counts toward the annual therapy threshold, but the multiple procedure payment reduction policy does not apply. In addition, if the Medicare Part B deductible has not been met yet, the allowed amount for the CTS codes would be applied to the Medicare Part B deductible.
As the CG codes are being applied to patients with a Medicare certification and POC, the billed codes would still follow similar guidelines to the other treatment codes being used for the patient’s POC.
Which other insurance companies have accepted these codes for payment?
As these are relatively new codes, the best course of action is to call the specific plan directly.
Can caregiver education codes be used for patient care conferences (patient not present but the caregiver is) and home assessments (patient not present but family is)?
Yes. As Gawneda noted during the webinar, CMS is revising its definition of caregiver to “an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation” and “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.” Assuming that all the other criteria for the relevant codes are met, you should be able to bill for these codes with patient care conferences and home assessments.
I assume Modifier GP is required when billing the new codes (i.e., 97550, 97551, 97552)?
Modifier GP—like modifiers GO and GN—denotes the provider type delivering the service. So if a PT completes caregiver training, apply the GP modifier to that respective CPT code.
What are the Medically Unlikely Edits (MUEs) for the new caregiver codes?
MUEs are used by Medicare Administrative Contractors (MACs) to reduce improper payments for Part B claims. However, not all MUEs are available for public record, and since not all MACs operate the same, the best course would be to call your region’s specific MAC for clarification.
Are there "minutes" required for the new CPT codes 97550, 97551, and 97552?
Code 97550 covers the initial 30 minutes of caregiver training, while code 97551 covers each additional 15 minutes.
Are the new caregiver training codes MDS allowable for Med A?
The present webinar covered material related to the final rule for the 2024 physician fee schedule pertaining to Medicare Part B payments. As it stands currently, there has been no statement from CMS pertaining to Part A coverage of this code. The best course here would be to contact your region’s MAC for more guidance.
How would you get consent from the patient from a patient with a severe TBI? Would that still be required, or if the caregiver being trained has medical power of attorney (POA), would they still sign a consent?
Consent to treat must always be garnered for patient care. In the event the patient cannot sign for themselves, a legal guardian still must provide consent for treatment. So, in the case of a patient with a Medical power of attorney, they would be the source for consent in all forms of treatment.
Will Medicare reimburse you for caregiver training on the same day that you treated the patients and billed four units?
“You will want to refer to the current version of the National Correct Coding Initiative (NCCI) edits. Version 30.0, which is effective for dates of service January 1 - March 31, 2024, does not prohibit the caregiver training services CPT codes from being reimbursed on the same date of service that the patient receives treatment,” Gawenda notes.
Other CPT Codes
When should someone use the CPT code 97012, mechanical traction? Is this the same as decompression?
This subject can be a tricky one depending on the source of the question. In a rehab therapy clinic staffed by PTs, OTs, and SLPs, the CPT code 97012 is used almost exclusively to bill for the modality that uses a traction device—not to be confused with manual traction. This can be the small home units or the larger tables with computers attached.
The question of decompression can have multiple meanings and is where this area gets a bit sticky. When a reaction force is delivered to the spine, the theoretical mechanism of treatment for mechanical traction is that decompression occurs at the spinal levels. This can be at the disc, facet joints, or other structures—the research is conflicted. Now, many chiropractic clinics market a separate device/treatment called decompression therapy. To the average rehab therapist, this is often viewed as traction with a different name, but chiropractors would say otherwise. But, I will leave that discussion and conclusion up to individual readers.
If a patient has met their therapy threshold for 2024 but they have had a new surgery or another prescription, can we submit it to Medicare along with an ABN?
The therapy threshold is not a cap. Therefore, if the patient comes to you with a new diagnosis, a new surgery, or a new medically necessary reason to seek treatment, Medicare will continue to pay for services. The important distinction when continuing care beyond the therapy threshold is that your defensible documentation supports the services, and you are able to show the medical necessity and continue to attest to it.
Can we charge for a re-evaluation code 97164 at the $2330 mark if there has not been a change in status or a new diagnosis?
Completing a re-evaluation and billing for one requires certain criteria for CPT code 97164 to be met. The threshold is not a hard stop, so if there is medical necessity for continuing care, then Medicare will continue to cover services—so long as your documentation supports it.
That said, if the patient has not had a change in status or a new diagnosis, and you don’t have a medically reasonable reason to complete a re-evaluation, it is not likely a good time to use this code.
For the $3000 targeted medical review threshold, does that mean Medicare will request or require medical records when they reach $3000?
Medicare does not review every single case that surpassed the therapy cap threshold for a targeted medical review. Instead, auditors will follow a set of criteria based on your practice and the patient’s history to determine which cases receive a review.
Assistant Supervision Requirements
If one therapist steps away for lunch, can another therapist step in to supervise and complete a patient’s treatment?
This question depends on the insurance payers’ specific rules for direct care and is of course dependent on safety. It is acceptable, depending on the type of insurance payer, for the patient of the therapist leaving for lunch and any patients that the “supervising” therapist (B) already has present.
For example, if both therapists have patients who are Medicare beneficiaries, then the only acceptable charge once therapist A goes to lunch would be group therapy—or no charge for one patient—as both patients require direct one-on-one care. However, if one of the patients has commercial insurance that allows distant supervision, then therapist B can provide one-on-one care to the Medicare beneficiary while the patient with commercial insurance completes supervised treatment.
As with most cases of this sort, if you are unsure of specific payer rules, the best course of action is to call the insurance payer directly or consult your payer contract.
Can you please clarify direct supervision for a therapy assistant under Medicare guidelines?
At present, CMS defines direct supervision as permitting“the presence and immediate availability of the supervising practitioner through real-time audio and visual interactive telecommunications through December 31, 2024, for outpatient therapy services.”
As Gawenda stated in the webinar, this is pushing toward a general supervision requirement, but CMS has not officially changed the wording to “general.” This may become so in the proposed rule for 2025, but CMS remains open to comment.
How do I find my state's practice act supervision requirements?
Unfortunately, there is no singular point to find each state’s specifics on practice acts and you must go directly to the source to find the relevant information. However, the Federation of State Boards of Physical Therapy (FSBPT) has a resource page that links to each state’s licensing site. Within those sites, you will find the practice act of that state.
If a physical therapist assistant (PTA) isn't allowed to sign a progress note, does that mean they are not allowed to bill for the exercising part they did?
No, the PTA should bill for the care they provided and affix the corresponding modifiers to delineate such treatment. In addition, the supervising PT should bill for the treatment they render and sign the progress note for it to be compliant with Medicare documentation standards.
Merit-Based Incentive Payment System (MIPS)
So, MIPS-eligible clinicians—does that mean those that are mandatory are required to report or just having 16 that can opt in to reporting?
The 15-provider mark is the threshold and differentiator between small and large practices under MIPS. Any provider can opt in to MIPS if they so choose. However, providers who don’t meet all three of the following criteria are not required to participate in MIPS:
- Billed Medicare for more than $90,000 in Part B allowed charges;
- Provided care to more than 200 Medicare Part B beneficiaries; and
- Provided 200 or more covered professional services under the Physician Fee Schedule.
Do hospital-based outpatient rehab clinics need or have to participate in MIPS?
As this blog from Clinicient lays out, hospital outpatient departments billing Medicare as an institution aren’t subject to MIPS.
What does a practice owner have to do if a MIPS-mandated therapist resigns and no longer works at your practice? Do we have to do anything for reporting?
According to Gawenda, “If the therapist resigns and no longer works at your clinic, there would be nothing to report since they are no longer treating patients at your clinic.”
Is there any consideration of allowing Rehab Agencies to participate in MIPS?“
At this time, no,” says Gawenda.
Does MIPS measure #291: Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease, require a threshold of 20 patients like the diabetes measure #127?
The denominator for MIPS measure #291 is “All patients aged 18 years and older with a diagnosis of Parkinson’s disease.”
So, if you don't use FOTO, there is no way to meet the requirement for MVP?
The decision to implement only Focus on Therapy Outcomes (FOTO) measures created some questions for comment during the rule proposal. CMS was urged to add different measures based on QCDR data to provide more equity and accessibility to the industry and patients served, but at this time, CMS has moved forward with this present MVP iteration. They will continue to be open to comment and examine feedback, so we are hopeful that with next year's rule, this will change.
In response to comments on the proprietary nature of FOTO, CMS states, “FOTO’s Public Access Survey provides a computer adaptive test (CAT) administration of the survey with scoring results provided on the last screen of the assessment without a fee.”
In the last few years, our small practice has not reached the goals of MIPs through the FOTO registry, and we have not had to submit the results despite doing the work and paying for the registry. Do we need to continue submitting to MIPs in the new year?
The specificity of answering this question would rest with the system you use for MIPS reporting. If you are having difficulty submitting for MIPS, you may want to consider using a qualified clinical data registry (QCDR). We have outlined the many benefits of using QCDR for MIPS in a separate blog post.
If a PT works in a chiropractic clinic, can the chiropractor also collect the Medicare copay at the beginning of the year?
As Gawenda explains, “The Medicare Part B program does not have a copay. There is an annual Part B deductible and then after that, the Medicare program pays 80% of the allowed charges and the remaining 20% is paid either by the beneficiary's supplemental plan, the beneficiary, or perhaps no one.
You will need to wait for the explanation of benefits from your Medicare Administrative Contractor to see what, if any, the financial responsibility of the patient is for the services provided.”
Do we need to document time in and time out for patients when they are seeing us for treatment?
In the context of Medicare compliance, time in and time out for treatment sessions is a requirement. The total time should reflect the time the patient was in the clinic and present for their appointment, and the allotted CPT code unit times should fall within this time frame.
Is CPT code 97530 (therapeutic activity) still not going to be allowed to be billed with the PT evaluation codes 97161, 97162, or 97163?
In early 2020, CMS had announced an intention to not pay for evaluation codes when 97530 was applied. This was consistent with their NCCI edit pairs announced for the 2020 final rule. However, after advocacy efforts by the APTA, CMS reversed course to allow for both pairs to be reimbursed.
Since that ruling, not all private insurers have followed suit, so if you are having issues with payment a call directly to a plan representative or your Medicare Administrative Contractor (MAC) is in order.
Is there a formula to find the change of payment in 2024 versus 2023 or OP facility?
Each year, the APTA updates a calculator they have put together in a spreadsheet format that reflects prospective payments based on geographic location using the final rule’s physician fee schedule, the multiple payment procedure reduction, and the 2% Medicare sequestration cut. The 2024 version has not yet been posted, but the link can be found on this page.
Well, there you have it—the final questions answered to our final countdown webinar covering the final rule for 2024. As with the many final rules, the rehab therapy industry was presented with some good news and some bad. But, just like last year, a little bit of advocacy by each individual can lead to some bigger changes to keep our industry running in the right direction. So, before you sign off and join some holiday parties and New Year’s countdowns, take a moment to do your part and urge action that benefits rehab and patients alike.