Earlier this week, Heidi Jannenga, PT, DPT, ATC, WebPT President and Co-Founder, and Dianne Jewell, PT, DPT, PhD, FAPTA, WebPT Director of Clinical Practice, Outcomes, and Education, hosted an hour-long webinar that unwrapped the many layers of MIPS and the 2019 physician fee schedule. Unsurprisingly, tearing through the layers of CMS’s latest gift revealed a crush of questions—many of which our experts didn’t have time to fully address. So, we compiled the most frequently asked ones for you to pick through at your leisure. If you can’t find the answer you’re looking for, please leave a comment at the bottom of the post, and we’ll do our best to hunt down your answer!

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MIPS

Eligibility

Do we determine our own MIPS eligibility—or does CMS make that call?

CMS will annually determine your eligibility during two different 12-month determination periods. For the 2019 reporting year, the first determination period runs October 1, 2017–September 30, 2018, and the second from October 1, 2018–September 30, 2019. During these determination periods, providers must exceed a low-volume threshold in order to be eligible for MIPS participation. The low-volume threshold is composed of the following criteria:

  • Bill Medicare for more than $90,000 in Part B allowed charges;
  • Provide care to more than 200 Medicare Part B beneficiaries; and
  • Provide Medicare patients with more than 200 covered professional services under the Physician Fee Schedule.

If you don’t meet any of those criteria, then you are completely excluded from MIPS participation. On the other hand, if you meet all three, then you are required to participate in the program. If you only meet one or two of these criteria during one of the two determination periods, then you’re not required to participate—though you may opt in to MIPS. To verify your eligibility status based on the most recent determination period, use this lookup tool after January 1, 2019.

So, the 200 beneficiaries (as noted in the low-volume threshold criteria) have to be seen by one therapist and not the entire practice?

That is correct. MIPS eligibility is determined on an individual basis.

Does MIPS apply to only Medicare, or does it apply to all insurances?

MIPS is a Medicare-exclusive payout system created by CMS. Providers who don't bill Medicare cannot participate.

Do the MIPS eligibility criteria apply to patients with Medicare Advantage plans—what about Medicaid?

No; the eligibility thresholds only apply to original Medicare beneficiaries.

Will PTAs need to report information for MIPS?

PTAs are not considered eligible providers, but if they are billing under a PT’s NPI, then their charges would count toward the PT’s total—and thus, could impact the PT’s eligibility status.

Does MIPS apply to our hospital-based outpatient clinic? What about rehab agencies? What if we don’t use CMS 1500 forms?

As of now, per the final rule, MIPS only applies to providers who bill using CMS-1500 forms.

Are rehab agencies eligible for MIPS—and will they ever be? What about skilled nursing facilities or facility-based outpatient therapy organizations?

Generally speaking, CORF and ORF-based therapists are not eligible for MIPS—and neither are providers in SNFs or facility-based outpatient therapy. This has to do with how the organizations bill. As the final rule states, “We are aware that facility-based outpatient therapy and skilled nursing facility claims do not contain the rendering NPI and usually contain just a facility NPI; therefore, facility-based outpatient therapy and skilled nursing facility claims will not be eligible for MIPS.” That said, we strongly recommend that every provider use CMS’s official participation lookup tool to determine eligibility. (Please note that this tool may not be updated for 2019 participation status until early 2019.)

Unless CMS plans to change the TIN and NPI criteria that defines a MIPS-eligible clinician, it’s unlikely that these providers will be included in the future.

Should we report MIPS if we are on paper and part of an ACO?

Some (but not necessarily all) members of Accountable Care Organizations may be required to participate in MIPS. Here’s an informational document from CMS that explains the interactions between ACOs and MIPS. We also recommend that all providers check their individual eligibility status with the QPP eligibility lookup once it’s been updated for 2019 participation.

If we choose to report as a group, does every provider in the group TIN have to participate, even if they wouldn’t have to based on the individual criteria?

Yes; if you choose to report as a group, then every provider in the group must participate in MIPS—even providers who don’t meet the eligibility criteria on their own.

I’m the only MIPS-eligible individual in my practice. If I choose to participate, does everyone in my clinic have to participate as well?

You could choose to participate only as an individual—which means your individual success or failure will affect the clinic’s bottom line. Alternatively, your practice could elect to report as group, which means all other providers—regardless of their individual eligibility status—would report as well. In this case, everyone’s collective performance determines the impact to the bottom line. (For the record, WebPT will allow you to report as either an individual or group within the app.)

If none of my individual therapists are eligible, is there a chance we’d still be required to report as a group?

Nope; if none of your therapists are eligible individually, then you won’t be required to report as a group.

I’m a provider who exceeds the low-volume thresholds for MIPS participation, but the QPP site lists me as ineligible. What gives?

As of the publication date of this FAQ, the QPP site had not yet been updated to reflect 2019 eligibility status.

Does the low-volume threshold apply to individual providers, or entire groups/clinics?

MIPS eligibility criteria—including the low-volume criteria—apply to individual providers.

I’m confused—I thought eligibility was determined at the individual level, so what’s the deal with the group eligibility criteria?

Required MIPS participation is always determined at the individual therapist level. However, practices that have two or more providers can also participate as a group as long as the group meets the criteria necessary to opt-in. The advantage of reporting as a group is that success is calculated as the average of performance for all therapists, rather than on individual therapist performance scores. The catch is that the decision to report as a group means all therapists in the practice will have to participate, not just the mandated ones.

It’s also possible for therapists in a practice who individually fall below thresholds to opt in as a practice group. To do that, a practice would first add up the cumulative number of Medicare beneficiaries served, the cumulative number of professional services provided, and the cumulative amount of allowable charges billed. If one of those aggregate amounts meets or exceeds the threshold, then the practice group can opt in to MIPS.

Are new providers eligible to participate in MIPS?

No; providers who are newly enrolled in Medicare during the performance year are not eligible to participate in MIPS. That said, if you expect to participate next year, you may want to voluntarily report in order to prepare without the added pressure of a potential penalty.

I’m part of a fast-growing practice. Can I be required to participate in MIPS halfway through the year?

No. If the individuals in your practice do not surpass the low-volume threshold during either of the two determination periods prior to the performance year, then they will not be required to participate in MIPS.


On the participation website for 2017 and 2018, there were exemptions for small and rural practices. Will this be the same for 2019?

Providers in small and rural practices are not automatically exempt from MIPS participation, but they (and other special status clinicians) can qualify for category re-weighting to help reduce the burden of participation. For example, special status clinicians qualify for activity re-weighting in the Improvement Activities category—essentially allowing them to report fewer activities.

Opting In and Voluntary Reporting

What is the difference between voluntary reporting and opting in?

Providers who opt in are choosing to participate in MIPS in the same manner as providers who are actually required to report. Thus, those who opt in are subject to payment adjustments based on their performance. Providers who voluntarily report, on the other hand, will receive feedback from CMS regarding their performance, but they are not eligible to receive a payment adjustment.

Who is eligible for voluntary reporting, and how do I indicate that to CMS?

Anyone who is not required to participate in MIPS may choose to report voluntarily. This is essentially “practice” reporting. It gets you into the habit of collecting MIPS data—without the risk of receiving a payment adjustment. Those who are interested must indicate their choice on the QPP website.

What is the deadline to opt in to MIPS?

Per the final rule, providers may choose to opt-in at any point during the performance period.

If only one of our therapists has to report, should all the rest opt in?

That’s a decision that only your individual practice can make. In some cases, it may be beneficial for everyone in the practice to work together to meet the reporting standards as a group—rather than put the burden of compliance on a single therapist. However, that isn’t always the case.

If I opt in but then realize reporting is not worth the effort, can I opt out?

No; once you opt in, you are required to meet the performance threshold or you will receive a payment reduction.

If two of the ten providers in our practice are required to participate in MIPS—and we decide to participate as a group—is that considered voluntarily reporting?

No; if you choose to participate as a group, you are opting in to participate in MIPS and thus are eligible to receive a payment adjustment.

If I don’t surpass the low-volume threshold and I don’t opt in to MIPS, is there anything that I need to do?

Nope—it’s business as usual for non-participating providers. However, if you’re close to the low-volume threshold, it might be worthwhile to consider voluntary reporting (an option that allows you to report for MIPS and get feedback from CMS without the pressure of a potential reimbursement adjustment) to help prepare you for future inclusion.

Is there a cost to opt in or to participate in voluntary reporting?

CMS does not charge providers who participate, opt in, or voluntarily report for MIPS. However, depending on your submission method, you may have to pay a third party to collect and submit your information.

Do I have to opt in annually—or is it once in, always in?

Your eligibility is reassessed every performance year, which means that for every year you fall below the low-volume threshold (but would like to participate), you’ll have to manually opt in.

Categories: Quality

Which quality measures can rehab therapists report?

Per the final rule, PTs and OTs can report on the following 11 measures:

Confirmed PT and OT Process Measures

  • BMI Screening and Follow-Up Plan (128)
  • Documentation of Current Medications in the Medical Record (130)
  • Pain Assessment and Follow-Up (131)
  • Functional Outcome Assessment (182)

Confirmed PT and OT Outcome Measures (Focus on Therapeutic Outcomes, or FOTO)

  • Functional Status Change for Patients with Knee Impairments (217)
  • Functional Status Change for Patients with Hip Impairments (218)
  • Functional Status Change for Patients with Foot or Ankle Impairments (219)
  • Functional Status Change for Patients with Lumbar Impairments (220)
  • Functional Status Change for Patients with Shoulder Impairments (221)
  • Functional Status Change for Patients with Elbow, Wrist, or Hand Impairments (222)
  • Functional Status Change for Patients with General Orthopaedic Impairments (223)

However, we anticipate that more measures will apply to PTs and OTs once CMS releases the 2019 measure specifications. We also anticipate that we’ll have more concrete information about SLP measures at that time.

What’s the difference between the process measures and the outcomes measures?

According to the U.S. Department of Health & Human Services, “process measures indicate what a provider does to maintain or improve health, either for healthy people or for those diagnosed with a health care condition.” The outcomes measures (i.e., the FOTO measures) focus on a patient’s functional status and how treatment helps that improve over time.

At what frequency do we have to report MIPS quality measures?

Reporting is triggered by certain CPT codes, as denoted in the measure specifications for each measure. These typically include evaluation and re-evaluation codes.

Can we still use G-codes to report functional outcomes measures for MIPS?

Yes. CMS is keeping FLR G-codes around for at least a year, which means you may use them to report some FOTO measures.

How does MIPS work for therapists who bill incident-to a physician—or who are reporting as part of a group that includes non-therapy practitioners?

Remember, “incident-to” means you are billing under the physician’s NPI number and have assigned the billing to the physician practice tax ID number (TIN). That means the physician will be credited with the volume of beneficiaries served, the volume of services provided, and the allowable charges billed to Medicare B. The physician also will incur the associated payment adjustment. Ultimately, it’s up to the physician practice to clarify for you whether you should be performing and documenting quality measures that are relevant to your specialty as part of the practice’s MIPS effort.

If you are set up to deliver outpatient therapy services in a physician’s office, but you have not assigned billing to the TIN and are not billing incident-to, then your participation in the MIPS program is the same as it would be if you were working out of a PT private practice. In other words, the low-volume threshold criteria apply to your NPI in your TIN—and payment adjustments are applied to you, not the physician.

I keep seeing "for patients older than 18 years" under the measure reporting requirements. What about patients who are under 18?

Each reporting measure outlines specific requirements that a patient must meet in order for a provider to include him or her in MIPS reporting. In most cases, the patient must be at least 18 years old, excluding measures 154 and 155 (both of which require the patient be at least 65 years old) and the FOTO measures (which require the patient be at least 14 years of age).

Some of the quality measures have different requirements (e.g., some only apply to patients who are 65 years or older). Do I report those measures only for patients who meet the requirements, or do I report every PT measure for every patient?

Only report the measures for patients who meet their requirements. Do not report every measure for a patient—unless he or she happens to fulfill every measure’s requirements.

What if the measures don’t apply to the majority of our patient population?

Every measure has medical exclusion criteria that are acceptable to report when a measure isn’t relevant to an individual patient. Submitting an exclusion code means the total number of patients who could have had a quality action performed is smaller. You are not penalized when that happens. However, unless you offer a very specialized therapy service, you will have a hard time defending that measures do not apply in most instances. That’s why it is essential that you verify your participation status with Medicare. If you are not mandated to report, you should evaluate whether it’s in your best interest to participate anyway based on the types of patients you manage, the measures available and their associated administrative effort, and the risk you are willing to incur to your bottom line. At the end of the day, it may not be advisable for you participate in MIPS in 2019.

How will WebPT add the quality measures to the initial evaluation documents? Will there be an alert system that will not allow note finalization without measure completion?

WebPT will add a separate MIPS tab to the SOAP notes—similar to the way WebPT included PQRS functionality. Additionally, there will be stopgaps put into place that will prevent the provider from finalizing the document without selecting a response to each qualifying measure in the MIPS tab.

Will WebPT automatically transfer quality measures directly from our documentation to CMS?

Yes; WebPT is considered a qualified registry for MIPS. So, if you purchase our MIPS package, you’ll document like normal in our EMR, and we’ll autofill the information into the MIPS measures, where applicable. You’ll then be asked to review the measure data to confirm that it’s correct. After that, WebPT will store that MIPS data—and send it off to CMS at the end of the reporting year.

Are there any measures for audiologists?

Audiologists are in the same boat as SLPs, in that they can participate in MIPS and will have measures available for quality reporting—but the final rule didn’t confirm what those measures will be. ASHA predicts that audiologists will have six measures they can report:

  • Medication Documentation (Measure 130)
  • Tobacco Cessation/ Screening (Measure 226)
  • Falls Risk Screening (Measure 154)
  • Falls Risk Plan (Measure 155)
  • Dizziness Referral (Measure 261)
  • Depression Screening (Measure 134)
In regards to measure 128 (Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up), can we ask patients for their height and weight, or are we required to weigh and measure patients ourselves?

Per CMS’s guidelines on Measure 128, “The BMI may be documented in the medical record of the provider or in outside medical records obtained by the provider.”

Categories: Improvement Activities

Which Improvement Activities can rehab therapists report?

While the 2019 list of activities hasn’t been finalized, the APTA created a list of the 12 Improvement Activities from last year that are most likely to apply to rehab therapists.

Are therapists allowed to choose which Improvement Activities they report?

Yep; it’s up to the individual or group to decide which Improvement Activities best suit their practice. You can take a look through the 2018 Improvement Activities on the QPP website. CMS is hoping to have that updated and ready to go in early 2019.

Can you provide a resource/examples to clarify the requirements for the Improvement Activities category?

In addition to our MIPS guide (which you can view here ), the APTA offers further clarification on both quality measures and improvement activities here.

Reporting

What’s the best way to report for MIPS? Can we submit through our EMR?

The answer varies depending on the performance category in question:

Quality:

WebPT is considered a qualified registry, so if you use WebPT—and have purchased our MIPS package—you will be able to report on measures for the Quality category through the app itself.

If you use a different EMR, you have a few options when it comes to submitting quality measures. Individual MIPS-eligible clinicians may use eCQMs, MIPS CQMs, or QCDR measures to collect information during the performance year. The eligible individual may either submit his or her data directly, or log in and upload measures. If the individual works in a small practice, he or she may collect and submit measures for the quality category via Medicare Part B claims.

In 2019, MIPS-eligible groups may use eCQMs, MIPS CQMs, QCDR measures, the CAHPS for MIPS survey, or administrative claims measures to collect information for the performance year. Groups may either submit their reports directly or log in and upload their measures. If a group works out of a small practice, it may collect and submit measures for the quality category via Medicare Part B claims. If a group consists of 25-plus clinicians, it may use the CMS Web Interface to submit quality measures.

Improvement Activities:

You have a few options when it comes to submitting items for Improvement Activities. First, you may submit Improvement Activities through attestation on the official QPP website. Additionally, you could work with a vendor and submit activities through a QCDR, a qualified registry, or an EHR system with that capability. Groups and virtual groups with 25 or more providers have the option of submitting activities through the CMS Web Interface.

WebPT will contain a feature that links to the Improvement Activities attestation page.

Will WebPT have reporting functionality in place for Members who are required to report in 2019? How will this work?

Yes; WebPT will have a MIPS feature that will allow Members to report quality measures. It will function in essentially the same way as our PQRS reporting feature—that is, because WebPT is already a CMS-approved registry, we will support registry-based MIPS reporting in the quality category for eligible practices. We will also provide an in-app link to the QPP attestation site for the Improvement Activities category.

Members will have access to a variety of training materials to help them learn how to use WebPT’s MIPS functionality to satisfy the reporting requirements.

What is the cost for WebPT’s MIPS product?

WebPT is in the process of finalizing its MIPS product details—including pricing. Stay tuned for more info.

What constitutes satisfactory reporting for MIPS?

Eligible providers must submit all applicable quality measures for patients seen throughout 2019. The minimum number of patients who must have quality actions performed is 20. For those 20 or more patients, you must perform the quality actions on at least 60% of the billable encounters (i.e., when you bill an evaluation and/or re-evaluation code). Remember, though, that these are minimums. Quality is a heavily weighted category for rehab therapists, so the more data you submit, the better. Also, remember that submitting the quality data code that essentially indicates that you didn’t perform a quality action—and that you don’t have an excuse for failing to do so—is a ding against completeness. MIPS is definitely not a program that gives credit just for submitting any old quality data code.

Performance improvement activities must be performed for at least 90 days within 2019. You can perform all of them in the same 90-day window or spread them out. Either way, remember that the approved activities have different point values. You need 40 total points to complete this category, which means you will be conducting multiple activities. The good news is that you simply have to affirm to CMS that you performed the activities. You don’t have to submit evidence of what they were or how it all turned out. Just keep that documentation in your records in case you ever need it in the future.

If I don’t begin reporting on January 1, does that mean I won’t comply?

No. The reporting criteria are designed to reflect the fact that many providers won’t be able to confirm their eligibility status until after the start of the reporting year. This is why, as noted above, providers only have to achieve 60% completeness in the quality category and complete their chosen improvement activities for 90 days (or one quarter of the year).

Will WebPT allow providers to report to Medicare without having to invest in additional outcomes measure software such as FOTO?

Not necessarily. If the non-specialty-measure-set measures are indeed finalized for PT and OT reporting, you should have enough non-FOTO measures to meet the requirements without having to purchase a FOTO subscription. However, the reporting requirements for the quality category also indicate the need to report on at least one outcomes measure, and at this time, the only MIPS-approved PT and OT outcomes measures named within the final rule are a set of FOTO measures. These measures are not publicly available to non-FOTO subscribers, which is why WebPT is petitioning CMS to categorize these measures as “unavailable.” This would mean there would technically be no “available” outcomes measures for PTs and OTs to report—and therefore, they could not be penalized for failing to do so. This would ensure that non-FOTO subscribers remain on a level playing field with those who pay to use the FOTO service. However, the results of our petition efforts remain to be seen.

All of that being said, there is a process called Eligible Measure Applicability (EMA), which is similar to the Measure Applicability Verification (MAV) process for PQRS. Per this process, even if the FOTO measures remain, we believe PTs and OTs could still fully comply with the submission of two high-priority process measures in lieu of submission of an outcomes measure.

Performance and Adjustments

How does our performance affect our bonus adjustment?

Your performance (i.e., the final number of MIPS points you earn) is held against a performance threshold—which, for 2019, is 30 MIPS points. That means at the end of the day, once the categories have been scored and weighted, you need 30 points to avoid a negative adjustment.

So, if you score more than 30 MIPS points in 2019, you will earn a bonus reimbursement—between 0.01% and 7%—on every claim in 2021, and that bonus is on top of the full reimbursement you'd normally receive. And if you earn more than 75 MIPS points, you’re eligible for an exceptional performance bonus that will be, at minimum, an additional 0.5% bonus adjustment (on top of your regular bonus adjustment).

On the other hand, if you fall below the performance threshold and score fewer than 30 MIPS points in 2019, you will receive a negative Medicare reimbursement for the 2021 payment year. Basically, Medicare will reduce your reimbursement for every claim by 0.01% to 7%.

If we participate in MIPS successfully, do we receive a one-time annual payment? If so, when?

No; the MIPS reimbursement adjustment is not a one-time annual payment. The payment adjustment will affect every Medicare claim in the calendar year two years after the performance year. So, your performance in 2019, for example, will dictate the reimbursement bonus or reduction you’ll see in 2021. (This is the same methodology that was used for PQRS payment adjustments.)

What is the likelihood that a participating PT will achieve the full 7% incentive payment?

It’s tough to say for certain, but based on the point opportunities afforded to PTs—as well as last year’s MIPS performance results—we’re betting it wouldn’t be very likely. Remember, MIPS is a budget-neutral program, so there must be enough submission failures to enable the bonuses. And in the first reporting year of MIPS, compliance rates were high—as in, above 90%—which means there wasn’t much penalty money to put toward the incentive payments. Additionally, MIPS caters primarily to physicians (which is part of why PTs are only eligible to participate in two of the four MIPS categories as the program stands), which makes it even tougher for a PT to receive the full 7% incentive—even if that therapist met all of the requirements that applied to him or her. It’s important to understand that unlike PQRS, which was a “pass or fail” program, MIPS scoring involves a complicated points system, and those points are determined based on a wide variety of factors—not solely successful measures reporting. (For example, providers can earn points for using Certified EHR Technology [CEHRT], and as the APTA has stated, “the problem is, PTs have been exempt from ‘meaningful use’ criteria promoting interoperability, and there is a lack of physical therapy-specific CEHRT.”)

Does the exceptional performance bonus stack on top of my base performance adjustment?

If you score above 75 MIPS points, then yes—your exceptional performance bonus will stack on top of your regular bonus adjustment.

If the PTs in my clinic report as individuals and one of them leaves halfway through the year, will my clinic be impacted by that therapist’s score?

If the providers in your clinic choose to report as individuals, then no one provider will affect the reimbursement for the whole clinic; that is, one PT’s score will only directly affect the Medicare reimbursements for claims with his or her name (and NPI) on them.

Is there a cap to the exceptional performance bonus adjustment?

Yes. According to the 2019 final rule, the exceptional performance bonus adjustment can range anywhere from 0.5% to 10%.

How do my category scores factor into my total MIPS score?

Here’s an example: You’re a PT, and it’s your first time participating in MIPS, so you’ll only be scored in the Quality and Improvement Activities categories. You struggled with the Quality measures, and only earned 10 category points. But, you knocked the ball out of the park in Improvement Activities and earned yourself the full 40 category points. So how does that affect overall score? Here’s what we know:

  1. It is possible to earn 100 MIPS points total under this program.
  2. Quality and Improvement Activities are weighted at 85% and 15%, respectively.

There's a one-to-one correlation between MIPS points and category weight, so we can safely determine that it's possible to earn 85 MIPS points from Quality and 15 MIPS points from Improvement Activities. Hypothetically, let’s say you got perfect marks in Improvement Activities, which netted you the full possible 15 MIPS points.

In this case, the only real calculations need to happen around the Quality score. Let’s assume that you reported as an individual, and that you earned 10 Quality category points out of a maximum of 60, or 16.67% of the possible Quality score. At that point, all you need to do is calculate 16.67% of the possible 85 MIPS points.

So 16.67% of 85 is a grand total of 14.17 MIPS points. Add that to the 15 points from Improvement Activities, and you get an overall score of 29.17 MIPS points. (Incidentally, this score would not meet the performance threshold of 30 points.)

How does performance assessment work if we choose to report as a group?

Your group’s performance will be aggregated to determine a final MIPS score—and every provider in that group will be subject to the payment adjustment. Theoretically, this means that your “high-performing” providers can help “cancel out” your “low-performing” ones—and that could, in some cases, help mitigate some of the risk to individual eligible practitioners.

If a part-time therapist opts in to MIPS at another clinic, will the reimbursement adjustment affect our clinic as well?

An individual’s MIPS score follows him or her regardless of where he or she practices. So, if the provider participated in MIPS in 2019, then come 2021, every Medicare claim that has his or her name on it will also contain the payment adjustment—positive or negative.

Is there a penalty if we don’t opt in to MIPS?

No; unlike PQRS, there is no penalty for those who do not opt in to the program. However, those who are required to participate will face a penalty if they don’t report.

If you are part of a virtual group and the members all have different MACs, how would payment adjustments be handled in 2021?

A virtual group is treated as one whole entity. So, regardless of location, specialty, or even MAC, every member will see the same adjustment come 2021.

If we choose to participate as a group and receive, say, a 2% payment increase in 2021, will all new providers who join our practice in 2021 receive the same increase?

No; MIPS performance and payment adjustments are tied to individual NPIs. Thus, providers who join your group will receive the payment adjustment they earned based on their own MIPS participation. Now, if you continue to participate as a group in 2021, then all providers—including therapists who only recently joined your practice—will receive the same payment adjustment in 2023.

Is it possiblethat one PT in our clinic could earn a positive adjustment and another one could earn a negative adjustment?

Yes; if your providers participate individually, then that is absolutely correct.

Will speech therapists be able to receive a positive adjustment when they can only earn 30 points out of the possible 60 points because they only have three quality measures?

Yes; CMS will invoke the MIPS Eligible Measure Applicability (EMA) process to determine whether or not an SLP could have reported more than three measures. Because SLPs can’t report more than three measures—which is something we’ll confirm once CMS releases the 2019 measure specifications—the SLP’s report will be classified as “satisfactory” and he or she won’t lose points from the Quality category.

If you receive a positive payment adjustment after reporting MIPS, does that mean you’ll meet the therapy threshold (a.k.a. the soft cap) or the targeted medical review threshold sooner?

Excellent question! No; a positive MIPS adjustment will not affect how quickly you hit the therapy threshold orthe medical review threshold. The dollar amount that counts toward the thresholds is based on the Medicare allowed amount for each CPT code—after Multiple Procedure Payment Reduction (MPPR) is applied and before the government’s 2.0% (net 1.6%) sequestration reduction is applied—not what you charge or receive from Medicare.

Is there a way to see a provider’s previous score before you bring him or her on as an employee?

No, there’s not. The only people who can access final MIPS scoring and feedback on the QPP website are those who submitted the information to CMS. The provider would have to disclose that information to you him or herself.

If you’re not currently treating patients but decide to start treating in the future, how will MIPS reimbursement adjustments work?

Your performance won’t affect your reimbursement—positively or negatively—until two years later when the associated payment year rolls around. So, say you step back into patient treatment in 2020. Though you’d have to report for MIPS, you wouldn’t see the payment adjustment that was associated with that performance until 2022. Therefore, your Medicare reimbursements would be neutral (i.e., sans positive or negative adjustment) until 2022.

Can I report more than six quality measures, and is there any benefit to doing so?

Yes; you can report more than six quality measures, and CMS will take the six highest-scoring submissions and count them in your final MIPS score. Here's a great example from the 2018 final rule:

"For example, if a MIPS eligible clinician submits 8 measures—6 process and 2 outcome—and both outcome measures meet the criteria for a high priority bonus (meeting the required data completeness, case minimum, and has a performance rate greater than zero), the outcome measure with the highest measure achievement points would be scored as the required outcome measure and then the measures with the next 5 highest measure achievement points will contribute to the final quality score. This could include the second outcome measure but does not have to."

 

Miscellaneous

During the webinar, you mentioned that we should keep in mind the “financial burden” associated with opting in to MIPS. Is this referring to the potential for a negative payment adjustment—or is there an actual cost to participating?

In addition to the potential for a negative payment adjustment, individuals who opt in should also factor in the additional time and resources necessary to successfully collect the required clinical data involved in performing the quality actions to report for MIPS—as well as the cost for registry submission software.

What are these MIPS virtual groups—and how might participating in one benefit a PT/OT clinic?

CMS is enabling solo providers and practices with fewer than 10 providers to form virtual groups in order to participate in MIPS together—and thus, aggregate their performance. As of now, there are no restrictions on provider specialty or location. However, the deadline to notify CMS you want to join a currently existing group or form a new one is December 31, 2018.

With PQRS, all of our data showing improvement was lost since we don't see patients for treatment until more than 90 days after the initial one or two visits. Will the data also reset with MIPS after 90 days, or will we be able to show improvement over a longer period of treatment time?

The MIPS Quality category is scored over the course of the entire year, so you don’t need to worry about losing data after 90-day periods. The Improvement Activities category is scored over a 90-day period, but there are many non-patient-related activities you may choose to report.

When will CMS update the eligibility lookup tool on the QPP website? What about the 2019 Quality Measures and Improvement Activities?

CMS doesn’t expect to have the lookup tool updated for the 2019 performance period until at least January 1—and possibly even a few weeks after January 1—due to time it takes to process claims submitted at the end of 2018. Additionally, CMS won’t have the 2019 Quality measures and Improvement Activities available at least until CMS releases the 2019 measure specifications. But, don’t panic; remember that the threshold for quality reporting is 60% on at least 20 patients (not 100%), and you only have to perform your chosen improvement activities for 90 days each—so you’ll still have plenty of time.

What are some examples of functional outcome assessments?

Per this APTA resource, “Examples of tools for functional outcome assessment include, but are not limited to: Oswestry Disability Index (ODI), Roland Morris Disability/Activity Questionnaire (RM), Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System (PROMIS), Disabilities of the Arm, Shoulder and Hand (DASH), and Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL).”

Do we need to complete MIPS training prior to January 1, 2019?

There isn't any required training for MIPS. However, CMS provided a handful of optional training videos on its website that explain MIPS participation. In the final rule, CMS also stated: "No cost technical assistance is also available by contacting the Quality Payment Program Service Center by phone at 1-866-288-8292, (TTY) 1-877-715-6222 or by email at QPP@cms.hhs.gov."

If you're talking about training to use WebPT's MIPS product specifically, we will definitely provide training when we release that tool. However, if you used the WebPT EMR for PQRS reporting, using it to report for MIPS will be just like riding a bike. We’ll have all of the same tags, prompts, and assists—except they’ll be labeled as “MIPS” rather than “PQRS.”

If we sign up for MIPS, is there a way to find out how we are doing in the four performance categories throughout the year?

First, note that only two of the four performance categories apply to PTs, OTs, and SLPs in 2019. For the quality category, WebPT will provide an in-app report to help you track your MIPS progress throughout the year (similar to the report we provided for PQRS).

What is considered a covered professional service in the MIPS eligibility criteria?

According to CMS, “one professional claim line with positive allowed charges” is considered “one covered professional service.” That means CMS is counting the number of billable codes on each claim—not the number of billable units.

If a patient comes in for multiple cases throughout the year, he or she only counts as one of the 200 patients noted in the low-volume threshold criteria, correct?

That is correct; each patient counts as one beneficiary regardless of how many cases he or she accumulates throughout the year.

Is MIPS set to only last for a certain number of years, or is it unknown at this time?

At this time, it looks like MIPS is around to stay. It’s possible CMS might change its mind and axe the program—just take a look at PQRS and FLR—but don’t hold your breath.

Where can I go for more MIPS information?

Look no further than WebPT! You can check your MIPS eligibility with this quiz, and you can take a look at what WebPT President and Co-Founder, Heidi Jannenga, PT, DPT, ATC, has to say about MIPS in this founder letter . And finally, we created a comprehensive Physical Therapists’ Guide to MIPS.

FLR

With FLR being cut in January, do Medicare patients have to continue completing outcome measurement assessments at the initial evaluation, every ten visits, and at discharge?

Once January 1, 2019, rolls around, you'll no longer have to report any FLR data to Medicare. However, that doesn’t mean that you shouldn’t still be collecting patient-reported outcome measurements from your patients; those can provide valuable information to inform the patient’s plan of care and goals.

How long does WebPT recommend we continue to report FLR?

We recommend continuing to report FLR until all claims for dates of service occurring in 2018 have been submitted to Medicare.

Will commercial payers continue to require FLR?

Some may, and some may not. You need to check directly with each individual payer in question, because your practice holds the contract with those payers. If you get written notification that they are discontinuing the program, let us know so we can spread the word!

Will Members need to manually opt out of FLR within WebPT come 2019?

Yes. Because FLR isn’t completely defunct (though it’s no longer required for Medicare), Members will need to manually opt out of FLR requirements in WebPT. We’ll release more information—including an instructional how-to—before the end of the year.

PTA and COTA Reimbursement Reduction

When are the PTA and COTA reimbursement reductions going into effect?

Medicare will reimburse PTAs and COTAs only 85% of the services they provide "in part" or in whole come 2022. You can read about the change in detail on our blog.

Will commercial payers also introduce a payment reduction for assistants?

There’s no way to know, but commercial payers do have a history of following Medicare’s direction, which means it’s certainly possible.

Does the change in reimbursement for therapist assistant-provided services apply to assistants who are directly supervised by therapists—and whose notes are signed by the PT?

Yes; you will need to apply the CQ (PTA) or CO (COTA) modifiers to all claims for services provided in full or in part by an assistant—regardless of the level of supervision that a therapist performs.

Does WebPT recommend waiting until 2020 to add CQ/CO Modifier?

Yes; the CQ and CO modifiers will not be required until 2020—and payment reductions will go into effect in 2022.

Do the CQ and CO modifiers replace the GP and GO modifiers, respectively?

No, you’ll need to use the appropriate therapy assistant modifier in addition to the appropriate therapy service modifier.

Will the reduction in payment for PTA and COTA affect inpatient services, including hospital-based services, as well as outpatient?

The payment reduction for services rendered by PTAs and COTAs will only affect claims billed under Medicare Part B, which primarily covers outpatient services.

Does this payment reduction affect SLP assistants?

No; the final rule states the following: “Although we generally consider all genres of outpatient therapy services together (PT/OT/SLP), we did not believe there are therapy assistants in the case of SLP services, so we proposed to apply the new modifier only to services furnished in whole or in part by a physical therapist assistant (PTA) or an occupational therapy assistant (OTA).”

If a PTA performs a whole service, will the PT still need to cosign—or is this dependent on state law?

A PT will still need to cosign for the service, regardless of the state. If you want to brush up on PTA billing, check out this blog post.

Is it true that the PTA reimbursement decrease does not affect Critical Access Hospitals?

Yep—CAHs will not be affected by the PTA reimbursement reduction, per page 638 of the final rule.

Miscellaneous

How do APMs work? Is it too late to apply?

Advanced Alternative Payment Methods (APMs) function as an alternative to MIPS. Advanced APM participants may earn a 5% lump-sum incentive for hitting certain thresholds. It’s too late to apply for an APM for 2019—participants must send in their APM applications between January 1 and April 1 of the year prior to the performance year. In other words, to participate in an APM in 2019 you needed to send in an application between January 1 and April 1 of 2018.

Since we’re still using the KX modifier after the therapy cap repeal, can you provide some suggestions for documentation that supports the continuation of medically necessary care?

We sure can. Check out our defensible documentation toolkit for detailed information to help you justify the continuation of your services beyond the therapy threshold amount.

How should I order modifiers once the therapy assistant payment modifiers go into effect? Would the KX modifier be listed at the end of the charge line?

According to this CMS source, “providers may report the modifiers on claims in any order.”

Will the Multiple Procedure Payment Reduction (MPPR) remain for 2019?

Yes; MPPR doesn’t look like it’s going anywhere.


Between MIPS, FLR, and reimbursement changes, CMS sure knows how to make the holiday season, well, exciting. If you have any remaining questions you’d like us to unwrap, leave ’em in a comment below.

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