Unwrapping the 2023 Final Rule: All Your Questions Answered

Introduction

Just as the last leaves fall from the tree and the days get shorter, the end of the year inevitably brings about the final rule from our friends at CMS. This year, compliance experts Rick Gawenda, PT, Founder and President of Gawenda Seminars and Consulting, and Heidi Jannenga, PT, DPT, ATC, Co-Founder and Chief Clinical Officer at WebPT, donned their “ugly” holiday sweaters to unwrap the final rule and spread some regulatory cheer for the new year.

As is often the case with our webinars, there was no shortage of questions and not nearly enough time to answer them all. Luckily, the elves at WebPT have been busy answering any mixed remainders (ho ho ho for puns!) to ensure you don’t miss a thing. 

(Psst, if you haven’t seen our 2023 final rule webinar, you can peep the replay here.)

Remote Therapeutic Monitoring (RTM)

Can the RTM tracking process be manual if a patient does not have a device to use? 

RTM does require a device for tracking and transmitting non-physiologic data, so manual tracking doesn’t fall within the scope of what RTM is. Fortunately, software can count as a device, so if your patients have a smartphone, they can take advantage of RTM through a qualified software app, like Keet Health. 

Are RTM codes subject to the therapy threshold and/or MPPR?

Because RTM codes are classified as “sometimes therapy” codes, they do count toward the annual therapy threshold but don’t fall under the Multiple Procedure Payment Reduction (MPPR) policy.   

Does RTM need to be done within a Medicare POC?

On page 121 of the 2022 final rule (the year RTM was introduced to rehab therapists), CMS states that “(w)e also note that the five RTM codes will be designated as ‘sometimes therapy’ codes, which means that the services can be billed outside a therapy plan of care by a physician and certain NPPs, but only when appropriate. While therapists’ services must always be provided under therapy plans of care, RTM services that relate to devices specific to therapy services, such as the ARIA Physical Therapy device (CPT code 98977), should always be furnished under a therapy plan of care.” 

“So, since the therapy-specific modifiers are required when billed by therapists and they are ‘sometimes therapy’ CPT codes, when RTM is performed by therapists, it’s done so under a therapy POC,” Gawenda clarified.

Can technicians assist in RTM for daily touch points if the plan of care is still monitored by a PT?

Per Gawenda, “No. RTM must be delivered under a therapy plan of care. This means that RTM must be provided by and/or monitored by a physical therapist, occupational therapist, speech-language pathologist, physical therapist assistant, or an occupational therapy assistant.

For RTM, which POS code do we use? And would we affix modifier 59?

“You would use the POS code that you use for the in-person therapy visits and modifier 95 would not be used,” Gawenda explained.

If the RTM codes are not a visit, would a patient have to pay a copay on the day they are billed?

Put simply, it depends on the insurance carrier. “For Medicare, the 20% coinsurance does apply for RTM services,” said Gawenda. “Regarding all other insurance carriers and the financial responsibility of the patient, you would need to contact that specific insurance carrier.”

MIPS 

What are the MIPS participation requirements that require? 

According to the Quality Payment Program’s (QPP) website, providers are required to participate in MIPS if, during both of the 12-month MIPS Determination Periods, they

• Bill more than $90,000 for Part B covered professional services;
• See more than 200 unique Part B patients; and
• Provide more than 200 covered professional services to Part B patients.

Other providers can elect to participate in MIPS, either as an individual or as part of a group, provided that 

• They’ve enrolled as a Medicare provider prior to that year; 
• They aren’t a Qualifying Alternative Payment Model Participant (QP); and
• They surpass at least one of the three low-volume thresholds.

If you’re unsure of these things, that’s okay—you can quickly check your eligibility (along with all the other providers’ in your organization) on QPP’s website. For any other general MIPS questions, check out our full rundown here.

What are the minimum reporting requirements that must be completed to earn 75 points and avoid a penalty?

This is a loaded question, but an important one as reaching that 75-point mark will determine whether you’ll be rewarded or penalized for your MIPS reporting efforts each year. We’ll provide a brief rundown here, but we also urge you to peruse our comprehensive MIPS guide, which details this process in full.

PTs, OTs, and SLPs who participate in the MIPS program are currently scored in two categories:

• The Quality category
• The Improvement Activities category

For small practices (with 15 or fewer MIPS-eligible clinicians under the same TIN), the weights for the two categories are as follows:

• Quality category: 50%
• Improvement Activities category: 50%

For medium to large practices (with 16 or more MIPS-eligible clinicians under the same TIN), the weights for the two categories are as follows:

• Quality category: 85%
• Improvement Activities category: 15%

In the Quality category, MIPS participants must report on at least six measures—one of which must be an outcomes measure. Each of these measures is worth a maximum of ten points. If fewer than six measures apply to the MIPS-eligible clinician or group, report on each measure that is applicable. To score the maximum points for each measure, MIPS participants must meet the data completeness standards, which are holding firm at 70% in 2023. However, for CY 2024 and 2025, the standard for data completeness is 75%.

For Improvement Activities, MIPS participants must attest to completing 40 points’ worth of activities. These activities are classified as either “medium” or “high” and can yield 10 to 20 points, respectively. As explained in our MIPS guide, to achieve maximal Improvement Activities scores, “individual MIPS participants must perform each of their chosen activities for a consecutive 90-day period at some point during the performance year. At least 50% of the NPIs that report as a group must complete these activities in order for the full group to receive credit.”

Again, that’s just a high-level summary of MIPS scoring. For a more detailed explanation, check out our guide to MIPS along with our MIPS-related resources available on our blog.

What’s the best way to gather MIPS information?

If you’re looking to report MIPS information, you first need to choose which reporting option makes the most sense for you: individual or group. Then, you must establish which reporting framework you want to use: traditional MIPS, Alternative Payment Model Performance Pathway, or MIPS Value Pathways. From there, you’ll determine which quality measures make the most sense for your reporting requirements, and then begin collecting data within those quality measures’ parameters. The easiest way to do this is with reporting tools—particularly those that are built into your EMR. You’ll also want to determine how you plan to report your quality measures data; according to QPP, quality measures data can be reported via:

• Medicare Part B claims
• Uploading them to the website
• CMS Web Interface
• Direct submission via Application Programming Interface (API)

Providers can also elect to use a Qualified Clinical Data Registry (QDCR) to submit MIPS quality measures on their behalf (like Keet). 

Do PTA sessions billed under a supervising PT’s NPI go into that PT’s MIPS reporting/score?

According to Gawenda, “Yes, and that Medicare beneficiary would then count as a unique Medicare beneficiary to that therapist.”

If you work in a POP, share a TIN with the MDs, and the PTs /OTs qualify as a group to report MIPS, but as individuals they do not meet the threshold amounts, do they have to report MIPS?

“Whether or not you are required to participate in MIPS is based on the individual NPI/TIN combination,” explained Gawenda. “If an individual therapist who has been at the same practice for both determination periods did not exceed all three of the low-volume thresholds during both determination periods, then they are not required to report MIPS in the 2023 MIPS Performance Period.”

Therapy Threshold

Do the Medicare therapy thresholds apply to Medicaid?

Medicare is a federal program with national regulations, whereas Medicaid programs vary from state to state. The best way to an accurate answer is to reach out to your state’s Medicaid representative for delineation on any therapy thresholds. It is worth noting, however, that many Medicaid plans utilize a prior authorization system independent of any therapy threshold dollar amounts.

Are threshold amounts based on diagnosis or just therapy provided?

The therapy threshold of $2,230 is the sum total amount for therapy services. In other words, if a patient receives PT for total knee replacement in January and uses $1,500 for that episode of care, but has a stroke in September requiring PT and SLP services, the patient would have $730 left until the threshold has been reached for the combined services of PT and SLP. OT is separate with its own $2,230 threshold.

Will the KX modifier reset on January 1, 2023, or do we have to remove the KX modifier and then reapply it once the patient has hit the threshold?

Since the therapy threshold will reset to $0 at the start of the new year, a KX modifier will not be necessary until the new threshold has been reached by a patient.

Can you give some examples of medical conditions that would be appropriate to continue physical therapy over the therapy threshold?

Any and all medical conditions can be appropriate to continue rehab services over the $2,230 threshold if they are deemed medically reasonable and necessary. To reiterate Jannenga’s point during the webinar, defensible documentation and appropriate billing practices are surefire safeguards in the event of an audit after surpassing a therapy threshold.

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Medicare Advantage

For Medicare Advantage plans, is direct, one-on-one care required for billing timed CPT codes?

Per Gawenda, “[i]nsurance carriers do not determine which CPT codes require direct one-on-one patient contact. That is determined by the American Medical Association (AMA). If a CPT code requires direct one-on-one patient contact per the AMA in order to be billed, that direct one-on-one patient contact requirement applies to all insurance carriers and not just the traditional Medicare program.”

Do Medicare Advantage plans require a POC signed by the referrer?

We would again refer readers to this blog post laying out the differences between Medicare and Medicare Advantage plans. While Medicare does require POC certification within 30 days of the initial visit for Medicare patients receiving physical, occupational, or speech therapy, some Medicare Advantage plans may not abide by the same POC certification rules as Medicare, while other MA plans might require prior authorization to a patient seeing a PT/OT/SLP. If you’re unsure of the requirements, check with the specific plan provider, as well as your state practice act.  

Medicare Conversion Factor

During the webinar, Rick mentioned the 4.47% conversion factor decrease was really 5.47%. Does this mean the same for PTAs?

We’ll let Gawenda take this one! “Due to changes in the relative value units (RVUs) of some of the CPT codes billed by PT and OT as well as changes to the Geographic Price Cost Index, CMS estimated an additional 1% decrease in payment on top of the 4.47% decrease due to the conversion factor. You may be higher or lower than that depending upon the CPT codes that you bill as well as the specific locality that your practice is located.”

What is the plan for the conversion factor and getting reimbursements to go up? What can rehab therapists do?

The hard fact is that reimbursement in its current form cannot go up without congressional action and subsequent directives to CMS. Luckily, we do tackle some ways to rebel against these changes in this founder letter. Our hosts also listed the current pieces of pro-rehab legislation that you can (and should) support to ensure a more reimbursement-friendly future for our industry. We strongly suggest leveraging resources the APTA and APTQI have created to support these bills, along with the ongoing advocacy efforts impacting rehab therapy. At the very least take five minutes to add your spin to one of their pre-drafted letters, and send that to your Congressperson.

Do we bill for home-based services the same way we would for in-office visits?

You’re not gonna like this answer, but it depends on the insurance carrier. For Medicare specifically, CMS states that providers can furnish outpatient services within the patient’s home. These services are payable by CMS under their current Medicare physical fee schedule rates. However, any additional costs (like travel, for instance) are not covered by the Medicare program. 

Gawenda adds that “If you are a private practice submitting claims on a 1500-claim form, the one item you would change would be the place of service code (POS). When seeing a patient in their home, the POS code is 12. When seeing a patient in your clinic, the POS code is 11.”

Billing and CPT codes

How many spinal mechanical traction treatments can be billed to Medicare in an episode of care?

Similar to the therapy threshold, CMS states that when using 97012 (mechanical traction), “documentation should support the medical necessity of continued traction treatment in the clinic for greater than 12 visits.” CMS goes further to nudge providers in the direction of implementing home-based traction units for further treatment that uses mechanical traction beyond one month.

Is concurrent treatment allowed in outpatient Medicare Part B beneficiaries?

No, concurrent therapy charges only apply for Medicare Part A claims, and are more commonly seen in skilled nursing facility settings rather than outpatient therapy clinics. And while concurrent therapy charges are not recognized by Medicare Part B, group therapy charges are billable and reimbursable for Part B beneficiaries.

Our clinic schedules patients for one hour. Can we see two patients that are Medicare Part B beneficiaries at the same time? If so, how would this be billed correctly?

As is often the case with Medicare, the answer is yes—but, it's complicated. If you are going to see two patients that have Medicare at the same time you are left with two billing options:

• The first is group therapy that is applied to both patients;
• The second is individual treatment units billed for the time spent on one-on-one care. 

This blog post provides more clarity on this topic.

Chronic Pain Codes

Is chronic pain a payable Medicare diagnosis code for physical therapy?

“Many times, therapists do not treat the chronic pain, they are treating the exacerbation of the patient’s pain,” said Gawenda. “Therapists would need to review the hundreds of pain diagnosis codes in chapter 13 of the ICD-10 Tabular List to determine which codes are applicable to this patient. In addition, due to the exacerbation of pain, there might also be additional diagnosis codes that are appropriate to place on a claim form such as difficulty in walking, muscle weakness, joint stiffness, etc. Keep in mind that all diagnosis claims placed on a claim form must be supported by either a physician’s order and/or the evaluation documentation of the therapist.”

Even though they are not reimbursed, should chronic pain codes be used for data collection?

Simply put, no. Here’s why according to Gawenda. “Since physical therapists, occupational therapists and speech-language pathologists are unable to prescribe medication, if required, you are not allowed to bill the chronic pain management codes to Medicare.”

Are there CPT codes for anxiety management by a PT?

To Gawenda’s and our knowledge, no.

I don’t know about you, but those questions and answers left us with a hankering for a hot toddy whilst seated fireside in our wool socks. 

A big thank-you to our compliance elves, Gawenda and Jannenga, for helping us make sense of the biggest final rule changes headed our way—ensuring each of us can make the most of the new year. For any other questions, leave ‘em in the comments section and we’ll do our best to answer them!