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Practice Affairs → Payment

Updates to payment policies by federal and private payers, strategies for navigating known payment issues as well as resources for correct coding and billing for physical therapy services, orthoses and supplies can be found here.

Numerous commercial payers including United Healthcare, Aetna, and Anthem, have suspended the 2% payment sequestration in alignment with the CARES Act for the remainder of 2020. As it relates to commercial payers, providers should be aware of the following:

  • Providers contracted with Medicare Advantage (MA) plans tied to the amount the providers would be paid under various Medicare payment systems, and/or tied to a portion of the plan’s capitation payments, generally should receive a 2% payment increase from the plans.
  • Providers not contracted with an MA plan also should receive at least a 2% increase because they are supposed to be paid at least what the provider would have received under original Medicare.
  • Some commercial contracts use Medicare-based rates. If the commercial plans using Medicare-based rates are applying sequestration on commercial claims, they may ‘forget’ to turn off these edits. Contact these plans individually to make sure they stop applying the 2% reduction.

Medicare

9/1/2020

CMS reinstated therapy code edits previously rescinded in April. This means that code pairs billed to a single beneficiary on the same day will not be allowed or will require modifiers in order to receive payment. CMS did not allow formal comments from stakeholders however, APTA submitted a letter to CMS and to the contractor processing the edits requesting a reversal of this decision.

The code pairs expected to be impacted are below:

97530 with 97116
97530 with 97164
97161 with 97140
97162 with 97140
97163 with 97140
99281-99285 with 97161-97168
97110 with 97164
97112 with 97164
97113 with 97164
97116 with 97164
97140 with 97164
97150 with 97110
97150 with 97112
97150 with 97116
97150 with 97164

More information can be found on CMS’ website: CMS coding edits. In the spread sheets found here, code pairs with a ‘0’ are disallowed and those with a ‘1’ can be billed with the appropriate modifier (59 or the applicable ‘X’ modifier).

Private payers may follow CMS’ lead-if you receive any communication from private payers that they are adopting these edits, please forward the information to: [email protected] with Attention Payment Chair in the subject line.


Proposed 9% payment cuts for Physical Therapy Services

APTA has produced a free webinar reviewing the CY 2021 Physician Fee Schedule proposed rule. You are encouraged to review and share this information on any and all social media platforms: APTA Review of the PFS rule.

Submit comments directly to CMS through the Regulatory Action Center: APTA Regulatory Action Center. Here you will find customizable template letters for clinicians, students and patients and detailed instructions on how to submit them electronically to CMS. CMS does have a character limit for submissions.

Everyone’s voice is needed! Please submit your comments today!


Physicians' Fee Schedule Proposed Rule

August 3, 2020

CMS released the Physicians’ Fee Schedule proposed rule this evening. This rule describes payment and regulatory policy beginning in 2021. APTA has conducted an initial review and determined that the proposed cuts to therapy services have been maintained and despite an increase in the work valuation portion of the physical therapy evaluation and re-evaluation codes, reimbursement will be reduced by 9% beginning in 2021 for therapy services.

APTA continues to study the rule and has a strategy in place to continue to advocate for waiving budget neutrality and eliminating the proposed cuts.

YOU CAN HELP!

  • A template letter is available through the Legislative Action Center at APTA.org for submission to your legislators. While legislators are out of session for the summer recess, they will be setting up virtual meetings in their home districts. Your presence and your communication regarding this issue is crucial! Ask them to support: Outpatient Therapy Modernization and Stabilization Act (H.R. 7154)
  • Educate your patients regarding the proposed cuts and urge them to contact their Legislators and ask them to support the Outpatient Therapy Modernization and Stabilization Act (H.R. 7154)
  • Spread the word via social media to “Fight the Medicare Cut.”

8/6/2020 UPDATE: CMS announced on 6/24/2020 that the ABN form (Form CMS-R-131) (exp. 6/20/2023) had been updated and approved by the Office of Management and Budget. The old form dated 3/2020 was set to expire 8/30/20, however, due to COVID-19 concerns, CMS has expanded the deadline for use of the renewed ABN to 1/1/2021. The renewed form may be implemented prior to the mandatory deadline. The ABN form and instructions may be found at: ABN Updates


Medicare Administrative Contractors (MACs) are resuming fee-for-service medical review activities. Beginning August 17, the MACs are resuming post-payment reviews of items/services provided before March 1, 2020. The Targeted Probe and Educate program (intensive education to assess provider compliance through up to three rounds of review) will restart later. The MACs will continue to offer detailed review decisions and education as appropriate.


6/25/20 CMS announced new flexibilities for clinicians participating in the Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS) in 2020. Clinicians significantly impacted by the PHE may submit an Extreme & Uncontrollable Circumstances Application which allows reweighting of some or all of the MIPS performance categories. Providers will be required to explain the practice impact due to the PHE. More information can be found on the QPP Covid-19 Response Page.


Public Health Emergency Extended

6/29/20: The department of HHS announced that the PHE which was set to expire on July 25, will be extended by 90 days. This includes continuing allowing the provision of telehealth services by physical therapists into the first of October. This is the second extension for the PHE.


Paycheck Protection Plan Updates


Durable Medical Equipment

On 8/17/20, CMS announced the resumption of routine inspections of DMEPOS providers and suppliers that had been suspended due to the PHE. More information is available at DMEPOS inspections.


CMS’ DME MACs have collaborated to create a single National DME MAC Education webpage. The page will include self service tools &resources, Medicare updates, allow confirmation of beneficiary eligibility, allow providers to check claim status, same or similar information and more. CMS DME MAC Education Resource


Orthosis payment denial and recoupments

CMS DME MACs are enforcing a long-standing regulation relating to the payment for custom, off-the-shelf adjustable and off-the-shelf orthoses. The Reasonable Useful Lifetime Standard (RUL) was established in 1990 and applied to orthoses and prostheses in 1992. The RUL states “The reasonable useful lifetime of an item of durable medical equipment shall be 5 years unless the Secretary (of Health and Human Services) has established an alternative reasonable lifetime for such item”. Alternative RUL’s have been established but not for upper extremity orthoses and supports. In January of 2019, the DME MACs began enforcing this rule, denying or recouping payment as far back as 3 years for orthoses and supports determined to be “duplicate” or “same or similar” to those dispensed to a given beneficiary within a 5-year period.

A coalition of stakeholders, organized and led by APTA in conjunction with the Hand Academy, collected data and met with CMS representatives in Baltimore to present information surrounding the issue. Following the meeting, CMS representatives made 2 requests: 1). Stakeholders should meet with the DME MACs and 2). Stakeholders should provide detail regarding the specific HCPCS codes affected and provide background information on the establishment of the standard and information supporting a more appropriate standard for upper extremity orthoses. On behalf of the group, Kara Gainer, APTA’s Director of Regulatory Affairs, requested the meeting with the DME MACs, which was declined due to the RUL being a national and not a regional standard. The second criterion was met in February and a document was submitted to CMS for review which included a recommendation to establish a 3-year RUL for UE orthoses. This recommendation was based on extensive research and discussion with thermoplastic manufacturers and experienced hand therapists. APTA followed up in April to determine if additional information was needed. We are anticipating the release of the proposed interim physicians’ fee schedule rule for 2021 (July 2020) which may contain information regarding CMS’ response.

In the meantime, the following information may be helpful to providers of orthoses and supports for Medicare beneficiaries:

Resources for Providers

  1. Prior to supplying or fabricating an orthosis for Medicare or Medicare Advantage (MA) beneficiaries, check to determine if they have had the same equipment issued in the past 5 years. You can find this information through the IVR for Noridian MAC’s (JA, JD) or through the provider portals for all jurisdictions (JB, JC will not provide this information via the IVR.). Many beneficiaries travel or may have multiple homes, so it may be necessary to check multiple MACs.

  2. If the same orthosis or support has been supplied in the past 5 years, the provider has the following options:

    1. If there has been a change in the patient’s condition justifying the orthosis, the item should be supplied and the KX modifier appended to the claim line along with the RT or LT modifier. The referring provider’s medical records demonstrating the change in medical condition should be submitted with the claim.
    2. If the patient requests a replacement due to wear, a replacement is not covered and this will be an out of pocket expense. An ABN should be issued and signed by the beneficiary. The item on the claim line should include a GA modifier to signify a signed ABN is on file along with the RT or LT modifier so the denial indicates “patient responsibility” instead of “provider responsibility.”
    3. The beneficiary requests a replacement due to loss, theft, or irreparable damage not related to daily wear, the RA, KX and RT or LT modifiers should be added to the claim line along with a narrative description of the circumstances, submission of a police report or insurance claim confirming the loss or theft. While not a CMS requirement, submitting a photograph of the damage is recommended.

    Noridian provides an “on demand” webinar with additional information regarding claim submission: Orthotics Same or Similar Webinar.

    A list of other webinars covering orthosis payment and coding can be found here: CMS Orthosis on demand webinars.

Private Payers

Sequestration Payment Reduction Updates

Numerous commercial payers including United Healthcare, Aetna, and Anthem, have suspended the 2% payment sequestration in alignment with the CARES Act for the remainder of 2020. As it relates to commercial payers, providers should be aware of the following:

  • Providers contracted with Medicare Advantage (MA) plans tied to the amount the providers would be paid under various Medicare payment systems, and/or tied to a portion of the plan’s capitation payments, generally should receive a 2% payment increase from the plans.
  • Providers not contracted with an MA plan also should receive at least a 2% increase because they are supposed to be paid at least what the provider would have received under original Medicare.
  • Some commercial contracts use Medicare-based rates. If the commercial plans using Medicare-based rates are applying sequestration on commercial claims, they may ‘forget’ to turn off these edits. Contact these plans individually to make sure they stop applying the 2% reduction.

Coding and Billing