The 2020 Proposed Rule: Bite-Sized Edition

Too much of anything is bad for you—even if it’s something you like. Too much sun will give you some gnarly burns. Too much exercise can damage your muscles or cause stress fractures. Even too much Chipotle can make you sick (much to my eternal disappointment). All humans need to avoid consuming too much of one thing—and reading through CMS’s annual policy changes is, inarguably, way too much. So, we’re gonna keep this explanation of the proposed rule light and totally bite-sized (think sliders and potato skins), so you can get a taste of what’s to come—without overfilling on dense legalese. 

Remember: The proposed rule is not a finalized piece of legislation, and these updates may not make it into the 2020 final rule. 

The deviled egg is in the details: CMS is still serving up the PTA and OTA reimbursement reduction.  

Last year, CMS announced a new reimbursement policy and unique payment modifiers for PTAs and OTAs. Starting in 2020, when PTAs and/or OTAs assist with (or completely supply) more than 10% of an outpatient service to a Medicare patient, the claim for that service must include a payment modifier (CQ for PTAs and CO for OTAs) in addition to the already-required therapy modifiers. Then, beginning in 2022, CMS will only reimburse 85% of the cost of service when the CQ or CO modifier is applied. 

CMS used this year’s proposed rule to clarify some of the foggier points of these new compliance requirements. Here are the big takeaways:

1. These modifiers will apply when a PTA or OTA assists with—or completely supplies—at least 10% of a service. (This includes evaluations, group therapy, and supervised modalities.) 
2. CMS plans to require a statement in the treatment notes (i.e., additional documentation) that defends the use—or omission—of the CQ or CO modifier. 
3. The CQ and CO modifiers will not apply to administrative tasks or services that can be completed by a technician or an aide. 
4. The CQ and CO modifiers will not apply to services that have been provided by (or are incident-to) a physician or another non-physician practitioner (NPP). 
5. These modifiers will also apply to inpatient facilities that supply outpatient services (e.g., CORFs, SNFs, and HHAs), but will not apply to CAHs because they are not paid under the Medicare Physician Fee Schedule. 

Sliders don’t actually slide around a whole lot—but reimbursements might in the near future.   

CMS is proposing a handful of serious changes to the calculation of relative value unit (RVU) values—some of which could significantly decrease rehab therapy reimbursement rates. It all boils down to CMS wanting to increase the value of E/M codes (i.e., codes in the range of 99201 and 99499). To maintain budget neutrality, the specialties that do not bill E/M codes (e.g., rehab therapy) will see a decrease in overall reimbursement levels. CMS projected that the cuts to the Physical/Occupational therapy specialty set could reach 8%.

This reimbursement cut is proposed to go into effect in 2021, and the APTA is working with other non-physician specialties to combat these suggested changes. 

Biofeedback RVU Adjustments

In 2018, the CPT Editorial Panel replaced code 90911 (biofeedback training) with 908XX (for initial contact) and 909XX (for additional contact). CMS wants to update those codes’ RVUs to 0.90 and 0.50, respectively.

You’re right—a kebab joke about dry needling is too on the nose. 

The birds are singing, the clouds have parted, and the sun is shining because dry needling might finally get its own specific CPT codes:

• 205X1: “Needle insertion(s) without injection(s), 1 or 2 muscle(s)”; and
• 205X2: “Needle insertion(s) without injection(s), 3 or more muscle(s).”

CMS is also considering classifying these codes as “always therapy” procedures (i.e., they could only be furnished by a PT, OT, or SLP), and is requesting the public’s feedback on that potential designation. 

Lettuce wrap up the confusion about the therapy threshold. 

CMS didn’t propose any changes to the therapy threshold (a.k.a. the therapy cap) this year. Instead, it simply clarified that the threshold—and even the higher targeted medical review threshold—is not a hard limit on therapy services. Therapists can still provide services after a patient has exceeded both thresholds, because the “use of the KX modifier confirms that the services are medically necessary as justified by appropriate documentation in the patient’s medical record.” 

Like a bundle of pepper poppers, MIPS is stuffed to the brim with...mostly the same stuff as last year.

Rehab therapists, for the most part, won’t experience many significant MIPS changes. CMS didn’t propose any adjustments to the low-volume threshold or the reporting process—and CMS wants to continue exempting rehab therapists from the promoting interoperability category. However, CMS did propose a new initiative—MIPS Value Pathways (MVPs)—with a goal of simplifying MIPS and creating a cohesive and less burdensome reporting experience. But, if adopted, MVPs won’t go into effect until 2021 (and there aren’t many details available at the moment). 

Higher Threshold

CMS wants to raise the bar next year: it proposed a 45-point performance threshold (up from this year’s 30-point threshold) and an 80-point exceptional performance bonus threshold. Basically, it’ll be a little bit harder to earn a neutral or positive payment adjustment through MIPS—and even tougher to earn an exceptional performance bonus. 

Quality Measures Changes

The biggest rehab-relevant MIPS proposals cropped up in the quality category. CMS wants to create a brand-new SLP specialty measure set, and add ten (and remove two) measures from the PT and OT specialty measure set. 

Additionally, CMS slated three other measures for removal—but if the measures are not removed, then PTs and OTs will have the option to report them in 2020. To round out the rehab therapy quality changes, CMS is batting around the idea of allowing PTs to report on two additional measures from other specialty measure sets. 

If you think any of these proposed changes will be a detriment to your practice or the rehab therapy industry, then now’s your chance to voice your concern to CMS! Go here, find and click the “Comment Now!” button in the upper-right portion of the page, and submit your comments about the proposed rule directly to CMS. Rehab therapists need to work together to advocate for the industry—and this is the perfect first step to take.