Halloween may be over, but if you didn’t get your fill of scares, I’ve got the perfect activity for you: reading through 1,401 pages of pure Medicare gobbledygook. Screaming yet? (Or should I check back at around page 500?) I kid, of course; there’s no need for you to slog through this year’s extra meaty Final Rule—which details the Medicare fee schedule and other important Medicare regulatory and reimbursement changes for physical therapy, occupational therapy, and speech-language pathology—because we’ve done all the slogging for you. (That way, you can save your appetite for a nice, tender slice of turkey—Thanksgiving is right around the corner, after all.) Here’s what PTs, OTs, and SLPs need to know about the 2017 Final Rule:

The new CPT codes for PT and OT evaluations and re-evaluations are officially a “go.”

As we previously explained here, the new set of evaluative codes for physical and occupational therapists replaces the following codes:

  • 97001
  • 97002
  • 97003
  • 97004

PTs and OTs must code for evaluation complexity in 2017.

A set of six codes (three for PTs and three for OTs) will replace 97001 and 97003. Why three codes in place of one? Because the new evaluation CPT codes require PTs and OTs to code for the complexity of each patient evaluation, and there are three possible levels of complexity:

  • Low
  • Moderate
  • High

Additionally, there will be two new codes to replace 97002 and 97004. (For a full list of all of the new codes—along with detailed descriptions of each—head to this blog post.)

But, they will not receive higher payments for more complex evals.

Not surprisingly, CMS did not divert from its proposal to apply the same valuation to all three codes (despite the fact that the codes were originally intended to have stratified values in accordance with increasing complexity). While, as we previously reported here, that doesn’t sit particularly well with a large portion of the therapy community, CMS reiterated its numerous concerns with adopting differential payments based on therapists’ coding decisions. Specifically, the authors of the Rule pointed out that:

  • Uncertainty around the utilization distribution of the three types of evaluations “make it difficult for us evaluate the HCPAC’s recommended values or to predict with a high degree of certainty whether physical and occupational therapists will actually bill for these services at the same rate forecast by their respective specialty societies.” (In other words, it would be nearly impossible for CMS to budget appropriately.)
  • Offering higher payments for higher-complexity evaluations could incentivize upcoding (i.e., therapists may characterize some evaluations as more complex than they actually are in order to obtain higher levels of reimbursement).
  • CMS felt that before therapists received differential payments based on complexity, they needed more time to “gain familiarity and expertise in the differential coding of the new PT and OT evaluation codes that now include the typical face-to-face times and new required components that are not enumerated in the current codes.”

There will be no change to the RVUs for PT and OT evaluation codes.

The current work RVU for both 97001 and 97003 is 1.20, and CMS finalized its decision to maintain that RVU for all six of the new evaluation CPT codes, offering this explanation: “We proposed this work RVU because we believed it best represents the typical PT and OT evaluation…Additionally, a work RVU of 1.20 is the longstanding value for the current evaluation codes, CPT codes 97001 and 97003, and thus, assures work neutrality without reliance on particular assumptions about utilization, which we believed was the intent of the HCPAC recommendation.”

However, the RVUs for the PT and OT re-evaluation codes are higher than originally proposed.

Many people who submitted comments on the Proposed Rule urged CMS to reconsider its valuation of the re-evaluation codes in accordance with significant changes “in practice…for the work of physical and occupational therapists.” After reviewing input from those commenters and further researching their arguments, CMS decided to assign the codes for both PT and OT evaluations “a work RVU of 0.75—the HCPAC-recommended work RVU for the PT re-evaluation and the PT low complexity evaluation.”

Furthermore, CMS included a paragraph reminding therapists to review the criteria for appropriate use of re-valuation codes, noting that “to be separately payable, the re-evaluation requires a significant change in the patient’s condition or functional status that was not anticipated in the plan of care.” (For a more detailed explanation of when it is appropriate to bill for a re-evaluation, check out this blog post.)

PTs and OTs are off the hook for proposed documentation changes related to the new codes.

Several commenters also requested that CMS either:

  • delay the implementation of the new codes entirely—most requested a delay of one year—to allow providers, coders, and billers ample time to practice, or
  • delay the enforcement of new documentation requirements related to the new codes.

While CMS has decided to move forward with its plan to implement the codes in 2017, it did agree to “delay changes to our current manual instructions for documentation for evaluations and re-evaluations in the Medicare Benefits Policy Manual (MBPM), chapter 15, section 220.3.”

The new codes are considered “always therapy” codes.

This means that regardless of what type of provider performs the services, the codes must be submitted with a therapy modifier—either GP or GO—to signify that the services were “furnished under a PT or OT plan of care, respectively.” It also means any related charges are subject to MPPR and the therapy cap.

The misvalued codes saga will continue in 2017.

Several years ago, CMS announced that it had begun work on an initiative aimed at identifying and investigating potential misvalued codes—specifically, a list of 10 rehab therapy codes that may require valuation revisions. This year, the news on the misvalued codes is, essentially, that there is no news. Per the Final Rule: “While we understand that, in some cases, it may take several years to develop appropriate coding revisions, we are, in the meantime, seeking information regarding appropriate valuation for the existing codes…We will include a valuation discussion during CY 2018 rulemaking of those codes for which we receive RUC recommendations by/at its February 2017 meeting.”

Curious as to which codes are on that list? Head to page 620 of the Final Rule and check out Table 24.

The Therapy Cap will increase—slightly.

As in previous years, CMS has bumped up the cap amount by a small margin. For 2017, the cap is $1,980 for occupational therapy services and $1,980 for physical therapy and speech-language therapy services combined. Additionally, the Rule extends the therapy cap exceptions process through December 31, 2017.

The manual medical review process has changed.

CMS also extended the manual medical review process—which affects claims submitted above the $3,700 threshold—through December 31, 2017, albeit in a slightly different format, per the recent MACRA ruling. As CMS explains, in contrast to previous years, “not all claims exceeding the therapy thresholds are subject to a manual medical review process as they were before. Instead…we are [now] permitted to do a more targeted medical review on these claims using factors specified in section 1833(g)(5)(E)(ii) of the Act as amended by section 202(b) of the MACRA, including targeting those therapy providers with a high claims denial rate for therapy services or with aberrant billing practices compared to their peers.”

There’s still no clarity around how—or if—rehab therapists can continue to report PQRS data.

As we reported last month, CMS indicated in its recent MACRA ruling that it will “allow non-eligible providers to participate in MIPS on a voluntary basis during the 2017 and 2018 reporting years.” While we hoped the 2017 Final Rule would provide details on the logistics of that voluntary participation, CMS instead dismissed the subject as “out of scope for this final rule”—though the agency did acknowledge receiving requests for guidance regarding the quality-data reporting future “for EPs, such as rehabilitation therapists, who are currently subject to PQRS, but will not be subject to MIPS until 2021 at the earliest.”

Changes to the physician fee schedule positively impact rehab therapists.

Compared to the 2016 fee schedule, the 2017 fee schedule will result in a very small—as in 1%—positive impact on total allowable charges. It’s not much, but every bit helps, right? 


Whew—that’s a lot of juicy regulatory goodness, amirite? Now, before you slip into a food—er, Medicare policy—coma, be sure to register for our free December 15 webinar with guest co-host Rick Gawenda of Gawenda Seminars. He—along with WebPT President and Co-Founder Heidi Jannenga—will provide a detailed tutorial on how to use the new CPT codes as well as a review of other therapy-pertinent components of the Final Rule. See you online!

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