In the first post of this three-part series, I provided an in-depth look at the history and philosophy behind the APTA’s proposed Physical Therapy Classification and Payment System (PTCPS). If adopted—and as of now, that looks pretty likely—this CPT coding overhaul would completely change the way physical therapists code for the services they provide. The kicker? PTs could be required to begin using the new codes—some of them, anyway—as early as January 1, 2017, with full implementation tentatively set for January 1, 2018.
If the thought of switching to a brand-new coding system—one based on sessions, rather than procedures—isn’t enough to raise at least one of your eyebrows, consider this: the system has spawned an uprising among various industry groups and leaders who vehemently oppose its adoption for a variety of reasons. In this second installment of my three-part report on PTCPS, I’ll lay out some of the biggest concerns—and the voices behind them—at the forefront of this contentious coding controversy.
1. The proposed codes are not available to all APTA members.
While the APTA dedicates an entire page of its website to PTCPS news and educational materials, there’s one glaring omission: the codes themselves. APTA has confirmed that the most recent version of the system includes “3 evaluation codes, 1 reevaluation code, and 5 examination and intervention codes for a total of 9 codes,” but the organization has not actually defined those codes.
According to Carmen Elliott, the APTA’s senior director of payment policy, that’s because the American Medical Association (AMA) is currently evaluating the codes—which makes them subject to strict AMA confidentiality rules.
But with the clock to implementation ticking—the evaluation component of the new system likely will go into effect January 1, 2017, with the intervention component tentatively following suit on January 1, 2018—therapists are running out of time to not only voice their opinions and concerns about PTCPS, but also educate themselves on how to use it.
After all, as I explained in part one of this blog series, once the new coding system goes live, the CPT codes rehab therapists have come to know (and, um, love?) likely will disappear. And even though, as Elliott pointed out, coding is “a very small piece of the overarching payment reform effort,” it’s certainly one that’ll affect providers in a very real—and possibly, very sudden—way.
2. PTCPS does not incorporate value/quality measures.
Of all the critiques PTCPS has drawn, this is perhaps the one that has gotten the most traction among those in the opposition camp.
That’s because, even though the new system allows for session-based coding and accounts for differences in patient complexity and severity, it still features a fee-for-service structure.
And that, critics say, does nothing to highlight the true value physical and occupational therapists provide—not only in terms of improved function and quality of life, but also with respect to long-term cost savings.
“We don’t believe that our value is measured in severity and intensity,” Larry Benz, president and CEO of Confluent Health and board member for the Physical Therapy Business Alliance (PTBA)—an organization dedicated to providing a “focused, agile, and unencumbered response to legislative and payment challenges to improve business conditions for independent physical therapy practices”—explained during a November 2015 episode of Therapy Insiders. “We believe that our value is really part of what I often refer to in old military terms as the force multiplier, or the ability for physical therapy to not be looked at in a siloed class, but how...we impact concurrent upstream and downstream costs of an episode of care.”
The Outcomes Debacle
Of course, wrapping value into a payment system is no simple feat. The most logical way to fill the PTCPS value gap would be incorporating outcomes into the payment system itself—something Elliott doesn’t foresee happening anytime soon. Part of the reason the proposed system doesn’t include outcomes is that there’s “not one standard tool PTs are using because they are in so many different practice settings with so many different tools,” Elliott explained. However, she said it’s something that “could be considered [in the future].”
Furthermore, Elliott says that while the APTA recognizes the benefits associated with outcomes tracking, the association questions its place in a payment system. “It’s important to understand that the purpose of the code is to report the services performed,” she said. “When we talk about quality indicators, that comes as an overlay.” Instead, Elliott and her APTA colleagues hope the new codes will “better demonstrate [to stakeholders] how therapists go about their clinical decision-making,” thereby leading payers to recognize the true value physical therapists provide. “Procedure codes don’t relate to the payer how the patient is progressing and getting better,” she said. “We are a standards-setting association, and considering some of the trends we have seen, we believe this system really considers the clinical decision-making of therapists and the diversity of the patients that they see.”
But according to Jeff Hathaway, president of the PTBA, outcomes data collection is something the PT community needs to consider now—before some outside organization or entity beats them to it.
“We need to be the ones coming forward with the design and how we’re going to use outcomes,” he said during the PTBA Town Hall meeting held on December 17, 2015. Furthermore, Hathaway believes the PT profession needs to redefine cost so it’s measured not in a fragmented, siloed manner—but rather, in a way that accounts for the total cost of care. Otherwise, payers will continue to measure cost and value using their own data indicators. “If we’re not the ones at the table developing the model, we’ll be hurt,” he said, noting that payers already are using data in a way that negatively impacts the PT industry.
The Fight Against Commoditization
One of the most commonly-cited effects of that negative impact is the commoditization of physical therapy—that is, payers’ tendency to view physical therapy as a cost to be controlled and minimized, rather than a valuable treatment option to be leveraged. And that leads to a “race to the bottom,” said Les Shute, the president and founder of 2PointOnline, during a November 19, 2015, PTBA Town Hall meeting.
Shute went on to explain that insurance companies love to pit large, corporate PT practices against small private practices because it allows payers to “tip the see-saw” from one side to the other, driving the rates for PT services lower and lower. And while large practices may be able to stomach those rock-bottom payments—because they receive them in bulk quantities—the so-called “little guys” can’t afford to accept them. But when both sides of the see-saw have a shared interest and a shared incentive, Shute says, the PT industry can band together to stop the race to the bottom dead in its tracks.
PTBA, for its part, has offered its own payment system proposal touted as “an alternative to the alternative.” Not surprisingly, one of the main differences between that proposal and PTCPS is the use of outcomes as a factor in payment. Of course, PTBA’s proposal—which dates back to 2012—hasn’t been officially vetted or tested in any way, and PTBA leaders are quick to admit that it has a long way to go before it could be considered implementation-ready. The way Benz sees it, though, that proposal has served its purpose, as it was meant to be “the start of a conversation—not an answer,” he said during the November PTBA Town Hall meeting.
3. Under the severity/complexity model, practitioners receive higher payments when they treat patients past the acute stage.
No payment system is immune to fraud and abuse. As Elliott so frankly put it, “To be honest, that happens in the current system.” Still, critics of PTCPS argue that the proposed system—which values codes according to severity/complexity—is inherently flawed in that it financially incentivizes providers to see patients with more severe and complex conditions. And as PTs know, many conditions that start out simple—and relatively easy to remedy—become more severe over time when left untreated. Thus, from a purely financial standpoint, the system seems to reward providers who put off treating patients until their conditions have gotten more severe and complex—a philosophy that does not align with scientific evidence that clearly shows a positive relationship between early intervention and overall value of care. “One of the issues we have with the complexity/intensity model is that it’s at the opposite end of the research,” Hathaway said during the December PTBA Town Hall meeting. “If we see the patient acutely, we’re going to save the most money, so it doesn’t make sense to support a payment system that rewards doing things further down the line.”
That, in turn, puts physical therapy care in a silo that prevents the outside world from seeing the value of PT through a long-term lens—one that highlights the downstream cost savings associated with early PT intervention.
“Look at the evidence,” Hathaway said. “The sooner you get to a patient, the better the result. So, we’re trying to drive that, and we think that any reform should really look at clinical pathway.”
Specifically, Hathaway and other industry leaders believe the system governing payment for physical and occupational therapy services should encourage therapists to begin treating patients as soon as possible, because “research shows that we deliver the best value the more acute we see somebody in the musculoskeletal world.”
Elliott, on the other hand, argues that this type of system-gaming should not even be an issue, as it goes against everything physical therapists stand for: “Physical therapists are extremely ethical providers, and that really distresses me when I hear [about potential gaming],” she said. “I don’t believe that will be the case.”
4. The subjective nature of the severity/complexity code model could put a greater burden on PTs to justify code selection within their documentation.
Most physical therapists already spend way more time on patient documentation than they’d prefer—and that’s due in large part to add-on requirements like PQRS and functional limitation reporting. At this point, no one knows how PTCPS will affect not only those programs specifically, but also documentation standards in general. After all, if payment is tied to severity/complexity, it’s safe to assume therapists’ documentation must support the levels of severity/complexity they select and code for. And that means documentation certainly will be different; however, the APTA is unwilling to speculate as to whether those changes will increase the amount of time therapists will spend on documentation. “Any system requires documentation,” Elliott said, adding that the new system will change documentation because the code descriptors will change. “Whether [those changes] will increase or decrease the amount of documentation that’s currently required, I can’t say.”
That uncertainty has some leaders questioning whether the system makes sense from a documentation standpoint—not only because it could put more of a burden on individual providers, but also because that additional labor wouldn’t necessarily pay off on a grander scale (whereas outcomes testing would more readily translate into a benefit for the greater good). And adding to the above-mentioned concerns over system-gaming, there’s the issue of upcoding: if the code selection criteria are too subjective, will therapists select higher-level codes—and exaggerate their documentation to match those selections—when lower-level codes are actually more appropriate to the severity and intensity of the patient? That’s just one of many questions that has yet to be answered.
5. Pilot testing exercises included only a small pool of geographically isolated practitioners.
As I explained in part one of this series, initial pilot testing of PTCPS involved 108 physical therapists spread among four sites: Charlotte, Chicago, Los Angeles, and Philadelphia. (A second round of testing included 33 physical therapists at two sites.) And even though the results yielded meaningful insights, the relatively small scale of the study has left some members of the PT community skeptical of its validity. Specifically, therapists and industry leaders have asked:
- Why the APTA didn’t conduct the test electronically, thus enabling them to get a more diverse and accurate cross-section of the profession as a whole.
- Whether the pilot test covered a sufficient variety of practice settings.
- Whether there was enough variance in testing participants’ years of coding experience. (According to the pilot study report published in March 2015, “These therapists were very experienced with coding, with over half reporting more than 11 years of coding experience.”)
For many close to this issue, the answers to those questions—or lack thereof—are concerning. Benz, for example, said, “The key is that it has to be field-tested over a broad array of private practices.” Furthermore, he believes such testing must prove that the system is:
- easily learned,
- reliable, and
Otherwise, getting consensus and buy-in throughout the PT community could be tough. The good news? Once the AMA workgroup releases its next version of the proposed coding system, the APTA will conduct further testing—and according to Elliott, the association is “exploring the option of electronic testing to reach greater masses.”
6. There has been a lack of collaboration and transparency throughout the PTCPS development process.
One would assume that a change of this scope—especially one being driven by a membership-based organization—wouldn’t take place in a vacuum. After all, APTA members paid for the research, development, and testing of the proposed system—which, in many members’ eyes, means anyone paying APTA dues should have access to any and all information related to those pursuits. Plus, by remaining open to suggestions and feedback, the APTA could ensure that the system meets the needs of all stakeholders. According to Elliott, the APTA has has done just that: “We’ve posted as much information as we can on our website, we’ve done presentations at numerous conferences...and we’ve met with stakeholders, including our members and various groups and leaders [within the PT community],” she said. “We feel we’ve really done our due diligence to make sure our membership is aware of what’s going on.”
But according to Hathaway, that hasn’t quite been the case—at least not consistently. Both PTBA and the Alliance for Physical Therapy Quality and Innovation (APTQI) have made multiple attempts—most of them unsuccessful—to collaborate with the APTA on the creation of the new coding system. In fact, as far back as three years ago, “We were told we would be kept in the loop; that didn’t happen,” he said during the PTBA Town Hall meeting on November 19, adding that historically, there hasn’t been great collaboration and transparency around payment reform on the part of the APTA.
While Benz revealed that the APTA has taken some steps toward fostering additional collaboration in recent weeks, he and other leaders remain concerned that it may be too little, too late.
With the evaluation component of the new coding system set to take effect on January 1, 2017, the PT industry is in the proverbial ninth inning of the PTCPS game.
“In part, we’re at the ninth inning because we kept being promised collaboration with the APTA with no sincere attempts to actually do so,” Hathaway said. “Maybe the Alliance had too much faith that there would be collaboration.” And that collaboration shortfall could, in Benz’s opinion, prove to be PTCPS’s downfall: “I’m a big believer that progress is made through deliberation,” he told Therapy Insiders back in November 2015. “The best ideas are the ones that get consensus and buy-in from their stakeholders.”
Nevertheless, Benz believes there is still time to right the ship: “It is still feasible [to complete further testing and revisions],” he said in a combined statement with Hathaway and PTBA board member John Childs. “We are encouraged by the recent announcement that the recent Physical Medicine Rehab AMA workgroup meeting in Miami that was supposed to meet in February has been cancelled. This should provide additional time for further testing.”
7. There are concerns over the system’s potential impact on reimbursements.
You’d be hard-pressed to find a PT who thinks the payment rates insurance companies offer for physical therapy services are in line with the true value of those services. So, it’s no surprise PTs are concerned about how a new coding system—especially one structured around sessions and based on severity/intensity—will affect the payments they receive in the future. And considering the pilot test results—which showed the majority of patients falling into the lower levels of severity—those concerns are legitimate. Plus, at this point, “there’s been no projection of what the codes will be valued at,” Hathaway said. “Just because valuation comes down the road doesn’t mean providers shouldn’t be studying this now and discussing it now.” Furthermore, as Benz pointed out on Therapy Insiders, “This payment reform issue is a penultimate issue.” That is, commercial payers are sure to adopt whatever coding system CMS starts using. So, any effect on reimbursements will be far-reaching—and long-lasting.
As the old saying goes, the only constant in life is change—and that’s certainly true in today’s healthcare environment. But, with change comes opportunity, and right now, physical therapists have the opportunity to leverage shifting payment methodologies to their advantage. “We need to be sure we’re part of the evolution of the healthcare system, and the way we currently do things can’t remain the same,” Elliott said. “When we provide that value to the patient we serve, we need payers and external stakeholders to understand that. And we believe this system is one answer in demonstrating to the public the value of the services physical therapists provide.” And while PTCPS may not be the answer everyone in the PT community is looking for, it has inspired a lot of discussion and action among therapists like Troy Bage who want to “make sure the future is as bright as the past.”
Still confused about the PTCPS debate—and why you, as a rehab therapy professional, should care about the way it all shakes out? Check back Monday for my third—and final—installment of this PTCPS blog series.
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