November is finally here, which means we here at WebPT can’t stop thinking about a juicy, flavorful, hot-out-of-the oven—Medicare Final Rule. While your tastebuds probably aren’t jumping with joy over the thought of chewing over a bunch of regulatory gobbledygook, the good news is that this year’s final rule shouldn’t be too tough to swallow (and if it is, you can always add more gravy). We’ve already picked out the most important pieces and served ’em up smorgasbord-style below. Here’s what’s on Medicare’s menu for 2016:  

The PQRS Primer

What’s Staying the Same

In the grand scheme of things, the 2016 PQRS requirements for satisfactory reporting aren’t much different from the 2015 requirements—at least not as far as PTs, OTs, and SLPs are concerned. Here’s what’s staying the same this time around:

  • The penalty for failing to meet the criteria for satisfactory reporting in 2016 is a 2% negative payment adjustment in 2018.
  • Each eligible professional (EP) must report on nine measures across three NQS domains for at least 50% of Medicare Part B FFS patients.
    • If fewer than nine measures apply to the EP, he or she must report on all applicable measures available for at least 50% of Medicare Part B FFS patients. If this is the case, the EP will be subject to Medicare’s Measures Applicability Validation (MAV) process, which allows Medicare to determine whether the EP should have reported on additional measures.
  • An EP who sees at least one Medicare patient in a billed visit during 2016 must report on at least one cross-cutting measure, even if fewer than nine measures apply to the EP.
  • CMS will not count any measures with a 0% performance rate.
  • The reporting requirements also will remain the same for EPs who choose to report via the Group Practice Reporting Option (GPRO), with one minor exception, which we’ve noted in the section below. To review the reporting requirements for GPRO, check out this blog post.

What’s Changing in 2016

Of course, a new final rule wouldn’t be “new” without a few updates. Here are some of the changes for this year:

  • There’s a total of 281 PQRS measures for 2016, up from 225 in 2015.
  • Measure 173 (screening for unhealthy alcohol use), which was available to OTs in 2015, is being replaced by the new measure 431 (unhealthy alcohol use: screening and brief counseling). Note: This measure is registry-based only.
  • Measures 154 (falls: risk assessment), 155 (falls: plan of care), and 431 have been added to the list of cross-cutting measures.
  • Measure 131 (pain assessment and follow-up) will move from the Community, Population and Public Health NQS domain to the Communication and Care Coordination NQS domain. Additionally, this measure will apply to SLP.
  • The MAV process for GPRO participants now will include a review of cross-cutting measure applicability.

What the Future Holds

As noted above, failure to satisfactorily report PQRS measures in 2016 will result in a 2% downward payment adjustment in 2018. In previous years—including 2015—the language in the Final Rule indicated that this penalty would remain the same for all subsequent reporting years. However, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) indicates that this adjustment will be in effect through 2018—thus indicating that the 2018 payment adjustment will be the last adjustment issued under the PQRS program. Essentially, this language authorizes the end of PQRS payment adjustments in 2018. If that is indeed the case, this year (2016) would be the final reporting year for PQRS.

The Vanishing Value-Based Modifier

Rehab therapists still are not eligible to participate in the Value-Based Payment Modifier (VM) program, which allows for differential Medicare payments based on quality and cost of care provided. In other words, based on their performance with various quality and cost measures, eligible professionals can receive either payment increases or decreases.

However, per MACRA, the VM program will expire at the end of 2018, with a new comprehensive program—known as the Merit-based Incentive Payment System (MIPS)—going into effect in 2019 (with reporting beginning in 2017).

The Migration to MIPS

Introduced as part of MACRA, MIPS applies to payments for items and services furnished on or after January 1, 2019 (with those payments being determined by reporting data submitted/collected in 2017). However, for services provided in 2019 and 2020 (and thus, for data collected in 2017 and 2018), MIPS only applies to:

  • physicians
  • physician assistants (PAs), nurse practitioners (NPs), and clinical nurse specialists (CNSs)
  • certified registered nurse anesthetists
  • provider groups that include the above-listed professionals

As this MedCity News article explains, “MIPS consolidates PQRS, the value-based modifier and Meaningful Use programs, and will affect about 30 percent of Medicare Part B payments.” Basically, the new program will use the data reporting and analysis mechanisms associated with the old programs, but will apply the results in a different way. The article also notes that eligible providers in Medicare Shared Savings Program Accountable Care Organizations “are exempt from MIPS if they meet certain revenue thresholds.” So basically, once MIPS goes into effect, eligible providers must either meet the reporting requirements for that program or participate in an ACO-type alternative payment model. Otherwise, they could face downward payment adjustments of up to 9% by 2022, this article notes. Unlike PQRS, though, MIPS also provides positive payment adjustments to those providers who perform well.

However, as it stands, rehab therapists aren’t eligible to participate in MIPS in either 2017 or 2018; thus, they will not be subject to any associated penalties or incentives. Theoretically, that means rehab therapists won’t be subject to any mandatory quality reporting requirements in 2017 or 2018 (assuming that PQRS reporting ends in 2016, as detailed in the above PQRS section). Keep in mind, though, that additional types of practitioners—including PTs, OTs, and SLPs—will become MIPS-eligible beginning in the program’s third year. So, by the time 2019 rolls around, rehab therapists may be required to report a variety of data points, including those associated with the former PQRS and VM programs.

The Conversion Factor Facts

As the APTA explains here, there will be an estimated payment rate increase of 0.5%, which “amounts to a conversion factor of $35.83.” However, the payment rate adjustment will have a 0% impact on the total allowed charges for physical and occupational therapy.

The Therapy Cap Chronicles

Despite the massive ongoing effort to repeal the therapy cap, it’s still in effect. And while the cap amounts for 2016 will increase slightly—from $1,940 to $1,960 for PT and SLP, combined, and $1,960 for OT—most rehab therapists agree that the cap negatively impacts patient outcomes and care quality. But clearly, it’s not going down without a fight—so if you haven’t yet joined the effort to stop the cap, do so here.


Mmmm—that’s a lot of delicious Medicare goodness. If you saved any room for dessert, now would be a great time to grab a slice of pumpkin pie. And stay tuned to the WebPT Blog. We’ll serve up even more Medicare details—including a second helping of PQRS facts—as we receive them.