Well, it’s finally here. On December 1, 2020, the Centers for Medicare and Medicaid Services (CMS) released the hotly anticipated 2021 final rule, and eager compliance experts wasted no time digging through its contents. But their digging unearthed legislative changes that are, to put it lightly, less than ideal for rehab therapists. This year’s final rule is not for the faint of heart—though there are some golden nuggets buried within. So, without further ado, here’s how the 2021 final rule affects PTs, OTs, and SLPs.
The 9% cut is here to stay.
Let’s get the biggest bombshell out of the way: CMS is moving forward with the payment increases to evaluation and management (E/M) services, and to pay for those increases, it will cut the conversion factor (i.e., the number that determines all CPT code payments) from $36.0896 to $32.4085. Ultimately, this means the 9% cut to PT, OT, and SLP services is officially happening.
When asked about these payment changes during a press call, CMS Administrator Seema Verma said, “Primary care providers are not being reimbursed appropriately for the time that they are spending with patients, and so we can’t continue to penalize those providers while continuing to have increases for providers that are doing more procedures. At the end of the day, we are reimbursing all providers for the time that they spend with patients.” While many affected providers have pleaded with CMS to reconsider these cuts in light of pandemic-related financial troubles, according to the above-linked article, Verma also said that “the problems providers face from COVID-19 have already been handled.”
PTs, OTs, and SLPs are less than one month away from one of the most significant industry-wide payment cuts in recent history. However, even though rehab therapists are entering the eleventh hour, they still have time to make one final move: harness the power of Congress. So, contact your federal representatives and ask them to support H.R. 8702—a bill that will temporarily increase Medicare payments for providers who are slated to receive cuts next year. (And have your patients contact Congress, too!)
PT, OT, and SLP evaluation codes will have slightly higher reimbursement rates.
The 9% cuts pose a substantial blow to the PT, OT, and SLP industries—but they do come with one small silver lining. CMS has acknowledged that PT, OT, and SLP evaluations “inherently include work associated with assessment and work associated with management, similar to the work included in the office/outpatient E/M visits, which involve time spent face-to-face assessing and treating the patient.”
Because therapy evaluations are so similar to E/M codes, CMS has decided that they also deserve a small payment bump. So, beginning in 2021, therapists can expect to see slightly higher payments for codes 97161–97168 and 92521–92524.
Before you get too excited, keep in mind that these payment increases will not offset the 9% cut. In fact, the 9% calculation actually accounted for those increases—but they did little to influence the net negative impact of the conversion factor reduction. Plus, CMS has admitted that “therapy evaluation services do not account for a large portion of allowed charges for these specialties.”
PTs, OTs, and SLPs will not be allowed to provide and bill for telehealth services beyond the COVID-19 public health emergency.
In the 2021 final rule, CMS plainly stated that once the public health emergency ends, Administrator Seema Verma will lose the temporary permissions that allowed her to give PTs, OTs, and SLPs the freedom to independently bill for telehealth. In other words, after the pandemic, rehab therapists will not be allowed to bill for telehealth—unless it’s billed incident-to a physician.
As for telehealth codes, CMS finalized its proposal to put 16 PT and OT codes and five SLP codes on a temporary telehealth list in an effort to give clinicians “the opportunity to conduct the kinds of review or develop the kind of evidence we usually consider when adding services to the Medicare telehealth services list on a permanent basis.” CMS also encouraged providers who bill these codes (and their patients) to provide feedback about their efficacy.
“Feedback from patients and clinicians is essential to helping CMS understand how the use of telehealth services may have contributed positively to, or negatively affected, the quality of care provided to beneficiaries during the PHE for COVID-19, enabling us to better determine which services should be retained on the Medicare telehealth services list until we can give them full consideration under our established rulemaking process.”
To help providers who bill telehealth incident-to another provider (e.g., therapists to physicians), CMS finalized its proposal to amend the definition of direct supervision. This will allow supervision to occur virtually through real-time audio and video technology, “expand[ing] access to needed care in communities that may not have a supervising physician on site.”
Other Remote Services
CMS will allow PTs, OTs, and SLPs to bill e-visit codes on a permanent basis. These codes are also now “sometimes therapy” codes—meaning they must be billed with a GP, GO, or GN modifier when billed by a PT, OT, or SLP, respectively. That said, CMS later noted, “After consideration of the comments received, we are finalizing our proposal to replace G2061–G2063 with CPT codes 98970–98972.” So, when billing for e-visits, PTs, OTs, and SLPs must use one of those CPT codes instead of the G-codes.
Additionally, CMS created two new virtual care codes that are available to rehab therapists:
- G2250: “Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment.”
- G2251: “Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.”
These new codes are valued the same as the codes for virtual check-ins.
CMS also made a decision regarding payment for telephone visits. After the conclusion of the COVID-19 PHE, CMS will no longer pay for telephone visit CPT codes 98966, 98967, and 98968.
Therapy assistants can provide maintenance therapy.
Back in May, to assist with the strain of the pandemic, CMS temporarily amended its policies to allow outpatient PTAs, OTAs, and COTAs to provide maintenance therapy. After receiving an overwhelmingly positive response to this change (and realizing it could “create greater conformity” between the standards of inpatient and outpatient therapy), CMS decided to make the change permanent.
So, from here on out, PTs and OTs can “delegate maintenance therapy services to therapy assistants on a permanent basis as clinically appropriate.”
Therapy students can assist with documentation.
This isn’t a change to current regulations, but rather a clarification made by CMS. According to the government agency, therapy students can document a session, and therapy providers simply have to “review and verify (sign and date), rather than re-document” the notes. This allowance helps ensure therapists “are able to spend more time furnishing therapy services, including pain management therapies to patients that may minimize the use of opioids and other medications.”
PTs and OTs cannot bill remote physiologic monitoring codes.
Again, this is not so much a regulatory change as it is a clarification. CMS has reiterated that remote physiologic monitoring codes—specifically 99453, 99454, 99091, 99457, and 99458—are listed under the evaluation and management (E/M) section of the CPT manual. As such, PTs and OTs cannot bill or receive payment for them.
The therapy threshold is rising slightly.
In a post-final rule release, CMS announced its intention to raise the therapy threshold for 2021. Next year, the annual therapy threshold will be $2,110.00 for PT and SLP services combined, and a separate $2,110 for OT services.
There are some minor tweaks to the MIPS program.
MIPS Value Pathways
MIPS Value Pathways (MVPs), originally intended to take effect in 2021, are “are a subset of measures and activities, established through rulemaking, that can be used to meet MIPS reporting requirements.”
Because of the COVID-19 pandemic, CMS is pushing out MVP implementation to 2022 and using that time to hash out the measures’ guiding principles and collaborative development criteria. Specifically, in the rule, CMS said, “We are open to considering candidate MVPs that are created utilizing the MVP development criteria, for specialties including physical and occupational therapy.”
Extreme and Uncontrollable Circumstances Application
Earlier this year, CMS published changes to the Extreme and Uncontrollable Circumstances Application, thus allowing clinicians to request MIPS category reweighting due to, well, extreme and uncontrollable circumstances. These changes:
- Allowed clinicians to request reweighting for any of the performance categories;
- Extended the application’s submission deadline for those who were affected by the PHE; and
- Prevented approved applications from losing their category reweighting by having already submitted data during the performance period.
In the 2021 rule, CMS finalized its proposal to retain those changes—with one exception: “If a clinician, group, or virtual group decides to submit data for the 2021 performance period, the data submission will override the application, and the clinician, group, or virtual group will be scored on the data submitted.” So, if your application is approved, don’t submit any data in 2021 unless you truly want to be scored.
CMS did not propose or finalize any changes to the low-volume threshold. Essentially, that means a large majority of PTs, OTs, and SLPs will not be mandated to participate in MIPS next year.
Performance Threshold and Category Weighting
In 2021, the MIPS neutral payment performance threshold will remain at 60 points, as finalized in the 2020 calendar year rule.
Additionally, CMS finalized its proposal to continue reweighting the promoting interoperability and cost category for PTs, OTs, and SLPs. So, if rehab therapists participate in MIPS in 2021, they will only need to complete the quality and improvement activity categories
CMS implemented a whole heap of changes to the quality measures that apply to PTs, OTs, and SLPs. Our experts will spend the next few weeks analyzing these changes, but for now, here are the biggest takeaways.
CMS added the following measures to the PT and OT specialty set:
- 283: Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management
- 286: Dementia: Safety Concern Screening and Follow-Up for Patients with Dementia
Furthermore, CMS removed the following measure from the PT and OT specialty set:
- 282: Dementia: Functional Status Assessment
CMS also added the following measure to the speech-language pathology measure set:
- 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
All in all, the 2021 final rule contained a lot of bad news for PTs, OTs, and SLPs—but rehab therapists still have a chance to make the most of the situation and petition for change. Have questions about the rule—or any other CMS regulations? Drop ’em in the comment section below.