Summer Reading for PTs, OTs, and SLPs: The 2023 Proposed Rule  

Summer is a fantastic time to catch up on reading, whether you’re enjoying a book outside in the shade or hiding indoors from the sweltering heat. And what would a summer reading list be without the latest set of proposed payment and regulation changes from CMS? Admittedly, no one is exactly eager to leaf through hundreds upon hundreds of pages of proposals, so we’ve hunkered down in our air-conditioned offices to pull out the most important and most relevant potential changes for rehab therapists.  

Expect very few plot twists to the Merit-based Incentive Payment System (MIPS) program.

The 2022 final rule didn’t see any major alterations to MIPS, and it would appear that 2023 could be the same, although there are a few small proposed changes worth noting for PTs, OTs, and SLPs.  

Small changes are coming to quality measures. 

For 2023, CMS is proposing to reduce the number of quality measures from 200 to 194, including the removal of 15 previous measures and the introduction of nine new measures. CMS is also proposing substantive changes to 75 quality measures, notably adding two measures to the PT and OT specialty set: 

• 048: Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 60 or Older, and
• 178: Rheumatoid Arthritis: Functional Status Assessment 

CMS is also proposing to create a Screening of Social Determinants of Health (SDOH) measure to the specialty set that would be available to PTs, OTs, and SLPs, with the aim of “(i)mproving the clinician’s understanding of the social obstacles their patients face.” SDOH insecurities specifically include: 

• Food insecurity, 
• Housing instability, 
• Transportation problems, 
• Utility help needs, and 
• Interpersonal safety. 

These SDOHs have been linked to increased hardship in patients receiving quality care as well as overall poorer health.

The quality measures scoring floor is going away. 

For quality measures scoring, CMS is proposing the removal of the three-point floor for measures that can be reliably scored against a benchmark, provided they meet the standard for case minimum and data completeness. The three-point floor would also be removed for measures without an available benchmark of either historical or performance period data or measures that don’t meet the case minimum, meaning these measures will receive zero points in each instance. Small practices would continue to earn three points.   

In the Improvement Activities Performance category specifically, CMS is proposing the addition of four new activities and the elimination of six existing activities. There are also proposed changes to five current categories, two of which are relevant to rehab therapists:

• IA_CC_14, “Practice improvements that engage community resources to support patient health goals” would have its title and description updated to include “drivers of health” and updating the activity ID and subcategory to Achieving Health Equity.  
• IA_PSPA_20, “Leadership engagement in regular guidance and demonstrated commitment for implementing practice improvement changes” would be removed. 

The performance threshold and data completeness standards hold steady.

CMS is proposing to continue with the Performance Threshold of 75 points for 2023. CMS also notes that the 2022 performance year/2024 payment year was the final year for additional performance threshold/MIPS adjustment for exceptional performance, as it will not continue into 2023 as stipulated by the Bipartisan Budget Act of 2018. 

As confirmed in the CY 2022 Physician Fee schedule final rule, the data completeness threshold for eCQMs, MIPS CQMs, Medicare Part B claims measures, and QCDR measures will remain at 70%, as finalized in the CY 2022 Physician Fee Schedule final rule; however, the proposed rule would increase that threshold to 75% for 2024 and 2025. 

Automatic reweighting and QCDR measure testing are unchanged. 

There are other areas where CMS is choosing not to propose changes for rehab therapists—or at least not yet. Although some clinicians would no longer be subject to automatic reweighting for CY 2023 in the Promoting Interoperability Performance Category, PTs, OTs, and qualified SLPs are among those who would continue automatic reweighting in the 2023 performance period. 

The Cost Category would also be reweighted to 0% for 2023. Furthermore, CMS is proposing to delay QCDR full-measure testing until the 2024 performance period, although the requirement for QCDR measures to be tested before inclusion into a MIPS Value Pathway (MVP) would remain in place.     

There may be new characters added to the MIPS Value Pathways storyline.

After much discussion, MIPS Value Pathways (MVPs) are inching ever closer, and with their introduction comes opportunities for clinicians to help improve upon it with their feedback. CMS is proposing to post draft versions of MVP candidates for a 30-day period on the QPP website to collect and consider feedback before addition to future proposed rules. They’re also proposing greater opportunities for MVP maintenance participation with an annual webinar for interested parties to provide additional feedback. 

The proposed rule also reiterated the CY 2022 Final Rule definition of MVP participants, which includes: 

• Individual clinician;
• Single-specialty group;
• Multispecialty group;
• Subgroup; and
• Alternate Payment Model (APM) entity.

For the 2023 performance year, CMS is proposing five new MVPs:

• Advancing Cancer Care
• Optimal Care for Kidney Health
• Optimal Care for Patients with Episodic Neurological Conditions
• Supporting Care for Neurodegenerative Conditions
• Promoting Wellness

MVP subgroups are coming—but not for a few years. 

Subgroups were also a focus of proposed MVP changes. While multispecialty groups are fine to report MVPs for the next three years, beginning in 2026, multispecialty groups would be required to form subgroups in order to report MVPs. Each subgroup would have to register between April 30 and November 1, and clinicians would only be able to register to one subgroup per Tax Identification Number (TIN). For 2023, 2024, and 2025, subgroup reporting is voluntary.  

For subgroups that are currently scoring for MVPs, measures calculated through administrative claims, Foundational Layer, Quality Performance Category, and Cost Performance Category are calculated and scored for the affiliated TIN group and then assigned to the subgroup. 

CMS wants feedback on MVPs.

Unsurprisingly, CMS is looking for input from clinicians on possible improvements to MVPs, including how to better collect data and develop scoring policies, how to align MVPs with both Alternative Payment Models (APMs) and APM Performance Pathways (APPs), and how to reduce the potential burden on clinicians. So if you have insights on how to improve MVPs, don’t hesitate to take advantage of the comment period, which ends on September 6, 2022. 

The fate of permanent telehealth reimbursements will likely remain a mystery.

Requests to add telehealth as a permanently reimbursable therapy service are slated to be denied yet again on the basis that CMS hasn’t received substantial evidence that it meets the “category 1” or “category 2” data. A sticking point for determination remains on “whether all of the necessary elements of the service could be furnished remotely.”

The proposed rule also maintains CMS’s position that PTs and PTAs will only be permitted to provide services via telehealth during the COVID-19 public health emergency (PHE) and for an additional 151 days past the end of PHE. After this period concludes, PTs will no longer be authorized to use these codes to bill for telehealth services.

According to the APTA, “[CMS] did, however, add a number of codes to the ‘category 3’ list of codes for which PTs can be paid when delivered via telehealth through 2023. As with all other category 3 codes, PTs’ ability to bill these codes in association with telehealth will cease 151 days after the PHE ends or until midnight on December 31, 2023—whichever comes first. Remember, none of this is effective until January 1, 2023, once the final rule is published.”

New CPT codes have been added to the list of temporary telehealth services.

Speaking of the category 3 list of allowable CPT codes PTs can use for telehealth services, there are a few new ones that CMS is thinking of adding to the fold: 97537 (community/work reintegration training), 97763 (orthotic/prosthetic management and/or training), 90901 (biofeedback training by any modality), and 98960–98962 (education/self-management training).

Here is a complete list of the proposed CPT codes that PTs may be able to use to deliver telehealth services—as long as they make the final cut. Remember, reimbursement for these will only last the duration of the PHE and the additional 151 days past its conclusion or until the end of CY 2023 (again, whichever comes first):

Telehealth legislation may be on the way. 

The good news? Recently, the House of Representatives passed HR 4040, a bill proposing to extend telehealth flexibilities until 2024. If eventually signed into law, the bill would not only help to solidify the rules CMS has extended during the PHE, but also allow flexibility in telehealth reimbursement beyond CY 2023.

Regardless, CMS continues to encourage feedback and supportive information for the possible inclusion of these services into permanent telehealth rules on a category 1 and 2 basis. By proposing that these services remain on the Medicare Telehealth Services List for the time being, CMS hopes enough rehab therapists will use it to provide concrete evidence needed to promote telehealth’s efficacy and necessity in musculoskeletal care. 

Feedback can be given electronically or via mail during CMS’s comment period. As these guidelines aren’t yet finalized, all rehab professionals should keep an eye out for the final rule this fall for greater clarity on what the actual lists and corresponding guidance will be. And, as always, WebPT will break down the most relevant parts for rehab therapists in our annual compliance webinar with Rick Gawenda. More information on this will be provided in the coming months.

Reimbursements could once again foil rehab therapy’s happy ending.

If you’re looking for good news about reimbursement rates, this year’s batch of proposed rules unfortunately has none to offer. According to the Calendar Year (CY) 2023 Medicare Physician Fee Schedule Proposed Rule, the proposed CY 2023 PFS conversion factor is $33.08, which is a decrease of $1.53 (or 4.4%) compared to the CY 2022 PFS conversion factor of $34.61. 

Breaking this down further, CMS estimates that, if implemented, this will result in a 1% cut to physical and occupational therapy payments. Speech therapists weren’t included on the estimated impact table—though audiologists were, and aren’t currently facing any estimated cuts.

The narrative around CO and CQ modifiers remains largely unchanged.

Consistent with last year’s final rule, CMS is proposing to apply a 15% payment reduction for PT and OT services provided by physical therapy assistants and occupational therapy assistants in whole or in part that have been affixed with CQ or CO modifiers, respectively. Payment will be made at 80% of the lesser charge or fee, with the remaining 20% being the beneficiary copayment. 

For the new discount, payment is made at 85% of the 80% of the permitted charges. As CMS explains, “the volume discount factor for therapy services to which the CQ and CO modifiers apply is: (0.20 + (0.80*0.85), which equals 88 percent.” What does that mean in plain English? Practices will continue to see a 12% reduction in reimbursements when using CO and CQ modifiers. Melissa Hughes explained this further in last year’s proposed rule recap.

If finalized, these cuts could have a negative impact on patients’ access to rehab therapy services—particularly those in underserved and rural communities. Fortunately, rehab therapists can take action to suspend the proposed therapist assistant cuts by supporting the Stabilizing Medicare Access to Rehabilitation and Therapy (SMART) Act (H.R. 5536). 

Remote therapeutic monitoring codes potentially face a rewrite. 

In the 2022 final rule, CMS introduced remote therapeutic monitoring (RTM) CPT codes while also signaling their concerns about the implementation and billing for these new codes. It should come as no surprise, then, that CMS has proposed a host of changes and revisions to the still-new RTM codes.

In discussing RTM CPT codes, CMS notes its concern with the inclusion of clinical labor in the RTM CPT structure, specifically “incident to” services provided. This is why, for 2023, CMS is proposing to create four new HCPCS G-codes, two with the aim of increasing patient access to RTM and two devoted to reducing the physician/NPP supervisory burden: 

GRTM1	Remote therapeutic monitoring treatment management services, physician or NPP professional time over a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes of evaluation and management services.
GRTM2	Remote therapeutic monitoring treatment management services, physician or NPP professional time over a calendar month requiring at least one interactive communication with the patient/caregiver over a calendar month; each additional 20 minutes of evaluation and management services during the calendar month. (List separately in addition to code for primary procedure.)
GRTM3	Remote therapeutic monitoring treatment assessment services, first 20 minutes furnished personally/directly by a nonphysician qualified health care professional over a calendar month requiring at least one interactive communication with the patient/caregiver during the month.
GRTM4	Remote therapeutic monitoring treatment assessment services, additional 20 minutes furnished personally/directly by a nonphysician qualified health care professional over a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month. (List separately in addition to code for primary procedure.)

What are the Relative Value Units (RVUs) for these new G-codes?

CMS is proposing a work RVU of 0.62 for GRTM1, 0.61 for GRTM2, 0.62 for GRTM3, and 0.61 for GRTM4, in line with the RUC-recommended values of CPT codes 98980 and 98981. These proposed G-codes would transpose the direct practice expense (PE) inputs associated with CPT codes 98980 and 98981 without refinement for HCPCS codes GRTM1 and GRTM2, while eliminating the clinical labor inputs for GRTM3 and GRTM4. CMS also notes that GRTM3 and GTRM4 would be designated as “sometimes therapy,” and would have to be furnished under a therapy plan of care. CMS also makes clear that with the introduction of these G-codes, RTM CPT codes 98980 and 98981 for treatment management services would be made non-payable by Medicare. 

What does this mean for rehab therapists?

We’ve continued to beat the drum for RTM as a part of CMS’ wider push for digital health solutions, and the proposed rule aligns with that belief, as RTM will likely remain intact and much the same in practice, despite the proposed billing changes. PTs, OTs, and SLPs are all listed in the registry, so RTM isn’t solely for PTs, and is definitely available to PTAs and OTAs. Therapists do have to be cognizant of the 16-day rule and de minimis standards when it comes to billing, which is why it’s so valuable to have a digital health app with an RTM dashboard to effortlessly track patients, devices, and plans of care.   

The direct supervision archetype remains much the same.

The 2023 proposed rule looks to continue with the changes to supervision guidelines as with last year. Direct supervision was previously defined using the term “immediate availability’’ which in turn was defined as in-person, physical, and not virtual. Starting March 31, 2020, the rule was modified to read, “supervising professional to be immediately available through virtual presence using real-time audio/video technology, instead of requiring their physical presence,” and has been proposed to continue as stated. CMS reminds readers that on December 31 of the year in which PHE ends, the rules for direct supervision would revert back to pre-PHE guidelines. As always, they remain open to comment on whether or not the changes to supervision during the PHE should be made permanent.

Chronic pain management adds new allies to its quest. 

CMS is proposing the addition of two HCPCS G-codes to describe and apply to monthly chronic pain management (CPM) services. 

• GYYY1 is the code applied to the initial 30 minutes of chronic pain management and treatment. This includes diagnosis, assessment, and monitoring, pain rating scale or tool application, care plan creation and maintenance that includes strengths, goals, clinical needs, and desired outcomes, overall treatment management, facilitation and coordination of any necessary behavioral health treatment, medication management, pain, and health literacy counseling, any necessary chronic pain related crisis care, and ongoing communication and care coordination between relevant practitioners furnishing care. 
• GYYY2 applies to any additional 15 minutes of chronic pain management and treatment (must meet the 15-minute threshold).

These codes are billed in a face-to-face manner and proposed for use by physicians, nurse practitioners, and physician assistants primarily in primary care and pain management settings; however, commentary is open for the role physical and occupational therapists play in chronic pain management for Medicare beneficiaries.

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These proposed changes are admittedly quite a lot to read, let alone absorb—more Russian literature than breezy paperback. But unlike your favorite books, you have some say in how this one ends. At this point, nothing is cast in stone, so be sure to offer your opinion on these potential changes before 5:00 PM on September 6, 2022. The APTA has even created a customizable letter template rehab therapists can use to encourage participation in the comment process.