Earlier this week, WebPT’s own Heidi Jannenga, PT, DPT, ATC/L, and Charlotte Bohnett teamed up to present a webinar detailing the most important regulatory updates that will impact PTs, OTs, and SLPs in 2018. During this hour-long session—which you can view completely free of charge here—our co-hosts covered a lot of legislative ground. And not surprisingly, they also received a lot of audience questions. While we didn’t have time to answer all of those questions live, we’ve compiled the most commonly asked ones—organized by topic—into the below FAQ. Can’t find the answer you’re looking for? Hit us up in the comment section at the bottom of the page, and we’ll do our best to get you the info you need.


What are the HIPAA implications of telehealth?

One of the biggest HIPAA hurdles with respect to telehealth is ensuring that the platform you are using is 100% HIPAA-compliant. In other words, you’re best off using a platform designed specifically for virtual healthcare visits.

I know Medicare doesn’t reimburse for telehealth, but how do I bill private payers for telehealth services?

Medicaid and some private payers will sometimes cover telehealth services. So, be sure to contact your individual payers to get a better understanding of their coverage rules for these types of services. According to the APTA, “If a private party is being billed, then the level 1 CPT/HCPCS codes that are used for traditional clinical visits should be used with an addendum attached to the charge that identifies the service as being provided via telehealth. Private payers may ask for an explanation of the charges, so it is important to be prepared to outline the reasoning behind the charges.”

Is there anything happening on the legal front that would potentially expand rehab therapists’ ability to provide and bill for telehealth services?

Yes! As Jannenga and Bohnett explained during the webinar, earlier this year, two telehealth-related bills hit the US House of Representatives floor: The Medicare Telehealth Parity Act and the Creating Opportunities Now for Necessary and Effective Care Technologies for Health Act 2017—better known as the CONNECT act. Ben Torres—a senior account manager and clinical specialist at Reflexion Health, a digital healthcare company—wrote an in-depth blog post on the CONNECT act, which you can read here. But, here’s the gist: if this bill is passed, PTs may have a clearer path toward delivering and receiving reimbursement for physical therapy telehealth services. For more information on telehealth in physical therapy, check out this APTA page.  


Are rehab therapy providers eligible for MIPS?

Not yet. Rehab therapy providers will not be eligible to participate in MIPS until at least 2019. To learn more about PT, OT, and SLP participation in MIPS, check out this blog post. Furthermore, as it stands right now, providers who furnish outpatient therapy services in a hospital setting are not eligible to submit MIPS data. According to this MIPS FAQ from APTA, the FI/MAC claims processing systems that these professionals are paid under can’t currently accommodate billing at the individual physician or practitioner level. We expect CMS and APTA to release more information as we get closer to 2019. When they do, we will definitely provide updates on the WebPT Blog, so be sure to check back.

What are the newly increased minimum thresholds for MIPS participation?

As explained in this document, in 2018, “eligible clinicians with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries” are excluded from participation in MIPS. In 2018, there is no opt-in option for providers who are excluded because they only meet one of the minimum criteria. (In other words, in order to participate, providers must meet both criteria.) For reference, according to WebPT’s in-house compliance resource, Betsy Hyder, “the minimums are measured from claims submitted in two consecutive 12-month periods (September 1, 2016, to August 31, 2017, and September 1, 2017, to August 31, 2018).” Providers who do not exceed the threshold during either period will be considered excluded.

What is group reporting?

Rather than reporting MIPS data as an individual, your practice can report on all of the claims for all providers together. This option is ideal for large or medium-sized practices. However, it’s important to note that—as explained here—if a practice elects to report as a group, then even those providers who don’t meet the threshold criteria individually would be required to report as part of the group. “Reporting as a group does not affect or change the way the MIPS composite performance score is calculated,” this resource notes. “The main difference is your entire group will have their scores averaged for each MIPS category.” Adjustments will be calculated based on those scores—and will apply to everyone under the group’s TIN.

Additionally, beginning in 2018, CMS is allowing solo practitioners and small practices to form or join a virtual group to participate with other practices. (According to CMS, this option applies to solo practitioners and groups of 10 or fewer eligible professionals. Click here to download CMS’s virtual group toolkit.)

Does MIPS affect G-code reporting requirements?

MIPS is totally separate from functional limitation reporting (i.e., G-code reporting). Per the Final Rule, there are no changes to functional limitation reporting (FLR). It continues to be a requirement in order to get paid for therapy services. You can learn more about FLR here. (As a side note, if you’re a WebPT Member, our built-in functional limitation reporting feature helps ensure you always remain compliant with all reporting requirements.)

Are patients with Medicare Advantage plans eligible for MIPS reporting?

As explained here, only eligible clinicians “who bill for Medicare Part B (otherwise known as the Physician Fee Schedule) or Critical Access Hospital (CAH) Method II payments assigned to the CAH” are included in MIPS. Thus, payments received from Medicare Advantage plans—and patients with Medicare Advantage benefits—do not apply to the MIPS program or its threshold criteria.

Is there any reason to continue reporting PQRS measures until MIPS goes into effect?

As of January 1, 2017, the Physicians Quality Reporting System (PQRS) is a thing of the past. As a result, PTs, OTs, and SLPs are no longer required to complete PQRS measures or submit PQRS G-codes to Medicare. However, we anticipate that rehab therapists’ reporting requirements under MIPS will be similar to the PQRS reporting requirements. So, while there’s no reason to continue submitting PQRS data, we’d recommend staying in the habit of performing quality measures. Additionally, we strongly encourage therapists to begin collecting and tracking their own quality data through the use of patient-reported outcome measures. You can learn more about that here.

Will WebPT have built-in MIPS functionality?

Absolutely! Our system will have a mechanism for MIPS reporting to ensure our Members stay compliant well before the go-live date for rehab therapists.

Are we off the hook for PQRS penalties now that the program is no longer in effect?

No. Eligible providers (EPs) who didn’t meet PQRS requirements in 2015 or 2016 will still be held financially accountable in 2017 or 2018, respectively—despite the fact that the PQRS program is no more. So, if you failed to report satisfactorily in 2016, you will incur a 2% downward payment adjustment on all Medicare Part B payments in 2018.

The Therapy Cap

What is the new cap amount for 2018?

CMS has elected to raise the therapy cap for occupational therapy as well as for physical therapy and speech language-therapy combined to $2,010 (up from 1,980) for the 2018 benefits term. But, that’s not the only new therapy cap development. Check out this post to learn more.

When should I apply the KX modifier?

You should only apply the KX modifier when your medically necessary care is going to exceed the therapy cap. If you affix the KX modifier in any other situation, it could be a red flag to Medicare auditors. Additionally, your documentation must support the medical necessity of continued care. As long as it does, and you apply the KX modifier appropriately, then Medicare should pay the claim. Remember, you shouldn’t fear the cap. The exceptions process exists for a reason, and if you don’t use it appropriately, your patients may not get the care they need. To learn more about the therapy cap and the current exceptions process, check out this resource. For more information on medical necessity, review this blog post.

Will we still use the KX modifier in 2018?

The therapy cap exceptions process, which involves use of the KX modifier, will expire December 31, 2017—if Congress does not move to renew it, that is. Keep in mind that Congress has renewed the exceptions process every year since the cap first went into effect, and if this happens yet again, then you will continue to apply the KX modifier as you normally would for claims that exceed the new threshold. However, there is no guarantee that Congress will act before the end of the year. There are also a couple of other bills in the works that could impact this process. You can learn more in our summary of the 2018 Final Rule.

How do I know if a service is medically necessary?

According to Jannenga, this is where your clinical judgment comes into play. If the patient continues to require skilled services that only a licensed rehab therapist can provide, then there’s a good chance those services are, in fact, medically necessary. On the other hand, if your patient has reached his or her functional goals and wants to continue receiving care that you do not believe to be necessary, then you can provide those services on a self-pay basis (by having your patients complete an ABN). In that case, you would not affix the KX modifier to the claim.

How do I know if a patient has exceeded the cap?

Prior to the start of a patient’s plan of care, it’s crucial that you calculate the patient’s progress toward his or her cap amount. To do so, start by finding out if your patient has already received therapy services within the past calendar year. If your patient can’t provide this information, we recommend reaching out your regional MAC. However, keep in mind that the amount Medicare has on file only accounts for claims that have been processed by Medicare—and not any claims that other providers are waiting to submit. If you are the first rehab therapist the patient has seen during the current benefits year—and you use WebPT—then you can keep a running total of the patient’s benefits use with our Medicare Cap Report. Learn more here.

Where do we stand on the bill to repeal the therapy cap?

As we explained here, “The Medicare Access to Rehabilitation Services Act…would effectively end the therapy cap and replace it with an all-encompassing targeted review process (much like the one that is currently used for claims exceeding $3,700). The bill has been sitting before Congress since February, but with its strong bipartisan support and backing by APTA, ASHA, and AOTA, there’s a lot of optimism surrounding its passage.”

How does the exceptions process work for patients exceeding the secondary, $3,700 cap?

With the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the old manual medical review process for claims exceeding the $3,700 threshold was replaced with a targeted review process. Per this update, recovery auditors cannot conduct these reviews; instead, CMS introduced Strategic Health Solutions as the supplemental medical review contractor (SMRC) that performs all of the reviews on a post-payment basis. To learn more about the targeted review process, check out this resource.

If a patient is nearing the cap, should I have him or her sign an ABN?

Not necessarily. You should only issue an ABN to a patient who is about to exceed the therapy cap if you do not believe that continued treatment is medically necessary. In that case, you should still submit the claim to Medicare—with a GA or GX modifier on the claim. This prompts Medicare to deny the claim and assign financial responsibility to the patient. Remember, if you submit a claim to Medicare without acknowledging that you know the services are either not covered or not medically necessary, and Medicare denies the claim, you may not go to the patient for payment.

Now, while you may be tempted to issue an ABN to any patient who is about to exceed the cap in order to ensure payment whether or not Medicare reimburses your claim, it’s imperative that you do not. So-called “blanket” ABNs represent a major Medicare red flag, which could put you at a higher risk for audit. To learn more about proper ABN use, refer to this blog post.

The Interstate Licensure Compact

What’s the biggest barrier to an interstate licensure compact (and across-state telehealth capabilities)?

One of the biggest barriers continues to be differences in state licensure requirements. As Jannenga explained here, “Currently, there is no clear consistency in physical therapy school curriculum or continuing education requirements from one state to another. So, physical therapy students—and practicing therapists—in different states may learn different protocols or be held to different standards. And that, in turn, means patients in different states may have vastly different care experiences.” Check out her post in full to see how she recommends we remedy the con-ed conundrum.

With the compact, would physical therapists be able to treat patients from out of state with an out-of-state prescription?

This would most likely depend on the terms of your individual state’s practice act. Fortunately, every state allows some form of direct patient access to physical therapy, so if a patient seeks services from you with an out-of-state prescription, you could perform an initial evaluation at minimum and consult your state practice act for direction on how to proceed.

Without the compact, how would a therapist licensed in one state provide services to a patient located in another state?

As far as we know, rehab therapists are restricted to practicing only in their licensing state. In order to provide skilled therapy intervention in another state, the therapist would likely need to acquire a new license from the new state. For the specific rules governing licensure in a particular state, please refer to that state’s practice act.

Does the interstate licensure compact only affect PTs?

Correct. The Interstate Licensure Compact that Jannenga discussed during the webinar is specific to PTs. You can learn more about it here.

Which states are included in the compact?

As of this post’s publish date, 14 states have enacted compact legislation, and two states have introduced compact legislation. To see a full list of states with compact legislation and follow compact-related news, check out the Federation of State Boards of Physical Therapy (FSBPT) website.

Direct Access

I’m still receiving denials on direct access claims, especially from Medicare. Why is that?

First of all, be aware that different payers—and different states—approach direct access in different ways. Furthermore, even if you practice in a state with very few—or even zero—limitations to direct access, that doesn’t necessarily mean your payers will reimburse for care provided on a direct access basis. For example, Medicare allows rehab therapists to provide an initial evaluation without a referral, but requires a signed plan of care before it will pay for additional services. So, make sure you’re familiar with the terms of your state practice act as well as all of your major payer contracts.

How does direct access work with Medicare?

Generally speaking, Medicare does not require patients to obtain physician prescriptions for PT services. But, it does require physician involvement in the plan of care. For details on those requirements, check out this blog post.

What are the direct access laws in my state, and where can I get the details?

WebPT just published several blog posts and a guide designed to help you better understand direct access laws in your state. Be sure to check them out.

CPT Codes

Are the new evaluation CPT codes (the ones implemented January 1, 2017) timed codes?

No. The new codes are not timed codes. Thus, you can only bill one unit of one evaluation code per evaluative episode, regardless of how long you spent providing the evaluation.

Where can I find an explanation of the changes to the physician fee schedule—including the CPT codes you discussed during today’s webinar?

You’ll find a breakdown of all the physician fee schedule changes from the 2018 Final Rule that will affect PTs, OTs, and SLPs in this WebPT Blog post. And one helpful webinar attendee let us know that the APTA recently published a calculator to help physical therapists determine how these changes will impact them.

I read that Medicare will not cover the new cognitive code 97127 and will instead replace it with code G0515. Is that true?

It is. As we discussed here, 97532 (cognitive skills development) is scheduled for deletion in CY 2018 and will be replaced by CPT code 97127 (cognitive function intervention). 97532 is a timed code reported at 15-minute intervals, whereas 97127 is an untimed code that is only reported once on each claim. However, CMS has developed its own, Medicare-specific code (G0515) to replace 97532. Like 97532, G0515 is a timed code reported at 15-minute intervals. Medicare will consider 97127 “invalid” and will not reimburse for it; thus, providers must instead submit G0515 on all Medicare claims. If you have questions as to which code your specific payers will accept, we recommend reaching out to those payers directly.

According to an APTA webinar, providers should use 97763 (orthotic and prosthetic subsequent encounters) instead of 977X1. Is that correct?

According to this CMS document, which was released on November 21, that would appear to be correct. 97763 should be used “to describe all subsequent encounters for orthotics and/or prosthetics management and training services.” We’ll update all of our content to reflect this change.


Are there any changes to CCI edits in 2018?

Yes. We’re actually in the process of sorting through all of the changes and compiling them into easy-to-understand resources, which we will make available on our blog. If you’re a WebPT Member, you’ll also notice that the new edit pairs will be available within WebPT come January 1, 2018. So, if you bill one of the new edit pairs, you’ll receive an alert asking if you would like to affix modifier 59 to the appropriate code, thereby indicating that you performed the services separately and distinctly from one another and are thus requesting payment for each.

I heard there were some changes with Tricare. Is that true?

Yes. There are two important Tricare changes. For starters, on January 1, 2018, Tricare North and South will merge to become Tricare East. As a result, you’ll need to complete the necessary paperwork to redirect your claims and update your payer IDs. If you use Therabill, WebPT’s billing software, we’ll actually be sending out more detailed information—and instructions for completing these steps—soon. Stay tuned.

Additionally, on December 12, 2017, President Trump signed into law the National Defense Authorization Act. As part of the Act, the Department of Defense will allow Tricare beneficiaries to access PTA- and COTA-provided rehab therapy services. While the change won’t take place immediately—and we’re not exactly sure about next steps—this is a huge win for both patients and providers. A big shout-out—and an even bigger thank-you—to everyone who participated in the advocacy work necessary to make this change happen.

Do you plan on adding more outcome measures to WebPT Outcomes?

Yes! We recently added three additional measurement tools to WebPT Outcomes: Hip disability and Osteoarthritis Outcome Score (HOOS), Knee injury and Osteoarthritis Outcome Score (KOOS), and The Modified Falls Efficacy Scale (MFES). But, we’re always on the hunt for more measures that will help our Members collect the most relevant outcomes data. So, if you’re a WebPT Member, be sure to give us your feedback here.

When will we be required to use the new modifiers in place of modifier 59?

Some payers are already accepting the new X modifiers in lieu of modifier 59; however, because it is not yet a CMS requirement, use of the new modifiers is not widespread among rehab therapists. Additionally, as explained in this WebPT Blog post, CMS “will identify situations in which a specific modifier will be required and will publish specific guidance before implementing edits or audits.” And of course, as soon as CMS releases any guidance relevant to PTs, OTs, and SLPs, we will announce it right here on the WebPT Blog.  

How should I go about billing for dry needling?

That’s quite a loaded question, and the simplest answer is, “It depends.” For a more in-depth discussion of the complexities associated with billing for dry needling, check out this blog post.

During the webinar, Heidi said that “out of all the patients with neuromusculoskeletal issues who could benefit from seeing a rehab therapist, only about 8% end up seeking out rehab therapy treatment. That means that about 92% of the patients rehab therapists could help never make it to a clinic.” Where did that stat come from?

This statistic actually came from a combination of studies, as explained in this blog post by Strive Labs Co-Founder Ryan Klepps. If you’d like to see the original studies, you’ll find them here and here.

Wowza—that’s a whole lotta regulatory knowledge. But, we know folks are bound to have more questions—and we’re committed to answering them as promptly and accurately as possible. So, if you’ve got a head-scratcher for us, leave it in the comment section below.