Ding-dong—the Sustainable Growth Rate (SGR) formula is dead. As of April 16, 2015—after 17 temporary patches—the wizards in Washington have permanently repealed the flawed SGR formula that threatened to significantly cut Medicare payments. Now, when payments exceed the growth in per-capita gross domestic product, PTs will no longer face reduced payments. Instead, they can look forward to a bit more stability, simplicity, and cash flow for the next decade. The new payment determination process begins with a static increase in payments across the board for the next several years. From July 1, 2015, through the end of 2019, the SGR replacement measure allots providers annual payment increases of 0.5%.

Next, starting in 2019, Medicare quality-reporting and incentive initiatives—like the PQRS, Value-Based Modifier, and Meaningful Use of Electronic Health Records (EHR) programs—will merge into one program, called the Merit-Based Incentive Payment System. The penalties for failure to comply with these individual programs will be abolished as well. Thanks to the new consolidated system’s additional funding, high-performing providers will have the opportunity to “earn additional payments from a pool of up to $500 million per year from 2019 to 2024,” with a pool of $20 million per year set aside specifically for smaller practices.

The new payment measures also make a strong push for value-based payment models. Eventually, providers will be required to adopt either a merit-based or alternative payment model. One hefty reason to select an alternative model: you’ll be eligible for a 5% annual bonus between 2019 and 2024. Plus, as this article explains, the new system will allow providers to choose from a menu of performance measures created by speciality-specific associations (like the APTA). It also will permit “professional organizations and other relevant stakeholders to identify and submit quality measures and updates to be considered for selection and used in the performance program.” Not sure you’re ready to skip down the yellow brick road to one particular model? No worries. Providers can switch models on a yearly basis.

The SGR repeal is certainly good news for practitioners, but permanent improvements to Medicare payments may still be somewhere over the rainbow. According to a report from CMS Chief Actuary Paul Spitalnic, the new payment measures may not be sustainable past 2025, and without subsequent legislation, “access to, and quality of, physicians’ services would deteriorate over time for beneficiaries.” Only time will tell how the measures—and payment reform itself—will shake out, but for now, the government seems to be taking a step in the right direction.

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  • Senate Repeals SGR in Landslide Vote Image

    articleApr 15, 2015 | 1 min. read

    Senate Repeals SGR in Landslide Vote

    Well, folks, the fix is in—the fix for the sustainable growth rate (SGR), that is. In a 92 to 8 vote, the Senate approved the SGR repeal bill, called HR2. In addition to an SGR repeal, the bill also officially extends the therapy cap exceptions process until December 31, 2017. This result is better than no therapy cap exceptions process at all; however, it’s disappointing to know that we came so close to achieving a full repeal …

  • Brace Yourself: Decreased Payments Might be Coming Image

    articleApr 14, 2015 | 3 min. read

    Brace Yourself: Decreased Payments Might be Coming

    As we warned at the end of last month , the times they are a-changin’. You’re likely well aware of the legislation that could do away with the Sustainable Growth Rate (SGR)—and extend the therapy cap for another two years. We had hoped to have better news for you at this point, but we’re still hanging tight while the Senate sings their own off-key version of Wilson Phillips’ “Hold On.” It’s April 14, 2015. That means the …

  • Common Questions from Our New PT and OT Evaluation Codes Webinar Image

    articleDec 19, 2016 | 20 min. read

    Common Questions from Our New PT and OT Evaluation Codes Webinar

    This month’s webinar on the new CPT codes was our biggest one yet—more than 11,000 people registered to attend. With such a large—and clinically diverse—audience, we received a ton of questions. And due to time constraints, our hosts—WebPT’s own Heidi Jannenga and compliance expert Rick Gawenda—weren’t able to get to even a fraction of them during the live broadcast. Not to worry, though; we’ve done our best to answer them all here, in one giant FAQ article. …

  • Why Physical Therapists Should Support the CONNECT for Health Act 2017 Image

    articleAug 14, 2017 | 6 min. read

    Why Physical Therapists Should Support the CONNECT for Health Act 2017

    The US Senate recently introduced the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act 2017 (S.1016) . If passed, the CONNECT for Health Act would remove several barriers to utilizing telehealth with Medicare patients—which would present a valuable opportunity to the physical therapy profession. Here’s why PTs should strongly consider supporting it: It will allow PTs to deliver, and receive reimbursement for, physical therapy telehealth services. As it stands, Medicare only provides …

  • CMS’s Final Bow: The 2019 Final Rule Image

    articleNov 5, 2018 | 8 min. read

    CMS’s Final Bow: The 2019 Final Rule

    Last week, the Centers for Medicare and Medicaid Services (CMS) published its 2019 final rule . Clocking in at just over 2,300 pages, the final rule isn't exactly a light read—especially because the legal lingo can be harder to interpret than Shakespearean verse. Luckily, we have the script—with all its twists and turns—decoded and ready for you to review. Here's the synopsis of all the physical therapy, occupational therapy, and speech-language pathology Medicare changes for 2019: Out, …

  • The 8-Minute Rule Showdown: Medicare vs. AMA Image

    articleNov 25, 2015 | 5 min. read

    The 8-Minute Rule Showdown: Medicare vs. AMA

    The guidelines for using the 8-Minute Rule are kind of like the instructions for building a piece of furniture from IKEA: they appear simple at first, but before you know it, you’ve been struggling for hours, you’ve got a lopsided futon, and there are seven leftover screws of various shapes and sizes scattered around your living room floor (maybe they’re just extras, right?). To make matters even more confusing, not all payers adhere to the same set …

  • Farewell, 97001: How to Use the New PT and OT Evaluation Codes Image

    articleOct 12, 2016 | 8 min. read

    Farewell, 97001: How to Use the New PT and OT Evaluation Codes

    Hear ye, hear ye: We hereby declare that as of January 1, 2017, all PTs and OTs must begin using a new set of CPT codes to bill for therapy evaluations and re-evaluations. Actually, if we are being perfectly accurate, we’re not declaring anything; CMS and the AMA are—and we’re merely the messengers. You might find it hard to believe, but with this CPT coding update, the evaluation and re-evaluation codes that PTs and OTs have come …

  • Denial Management FAQ Image

    articleMay 26, 2017 | 22 min. read

    Denial Management FAQ

    During our denial management webinar , we discussed the difference between rejections and denials, explained how to handle both, and provided a five-step plan for stopping them in their tracks. The webinar concluded with an exhaustive Q&A, and we’ve amassed the most common questions here. Insurance Issues Claim Quandaries Compliance Qualms Documentation Dilemmas Front-Office Frustrations Insurance Issues We’ve had issues with auto insurances denying 97112 (neuromuscular re-education) for non-neuro diagnoses, even in cases when the patient’s medical …

  • Double Duty: How to Bill for PT and OT on the Same Day Image

    articleNov 12, 2018 | 6 min. read

    Double Duty: How to Bill for PT and OT on the Same Day

    In many cases, physical therapy and occupational therapy go together like peanut butter and jelly. PTs and OTs often share similar goals and interventions, treat the same types of patients in the same settings, and get confused by the billing rules that apply to our respective specialties. This confusion leads to quite a few questions, including this head-scratcher: how does one bill for OT and PT provided to a single patient on the same day? While the …

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