Payment and Policy for PTAs

• PTAs play essential roles in the delivery of quality care for our patients and we are very disappointed that Congress established a payment differential.
• Unfortunately, the differential is not unusual: other essential health care providers, like physician assistants, clinical social workers, and nurse practitioners, are paid at 85 percent of the fee schedule. This speaks to an increasingly challenging payment landscape across health care.
• APTA is fighting to protect payment wherever possible. For example, earlier this year we prevented CMS from devaluing care if PTAs and OTAs were furnishing care jointly with the physical therapist or occupational therapist, respectively.
• APTA is also advancing alternate payment models that don’t rely on a fee for service system to deliver care and that recognize the value of inter-and intra-professional care.
• Please check out the December blog post by David Harris, chief delegate of the PTA Caucus, in which he urges all PTs, PTAs, and students to stay involved—because the battle for quality health care and appropriate payment is always ongoing.

The 2020 Physician Fee Schedule (PFS) rule builds upon prior CMS rulemaking to implement the Bipartisan Budget Act (BiBA) of 2018 requirement that outpatient physical and occupational therapy services furnished in whole or in part by a therapy assistant on or after Jan. 1, 2022 must be paid at 85 percent of the PFS amount. The reduced payment rate is applicable when payment is made under the PFS to therapists in private practice, outpatient hospitals, rehab agencies, SNFs, HHAs, and CORFs. The BiBA also required that CMS establish a modifier to identify these services that must be reported on relevant claims beginning on Jan. 1, 2020.

In the CY 2019 PFS final rule, CMS established two modifiers: CQ, which identifies services furnished in whole or in part by a physical therapist assistant (PTA), and CO, for services furnished in whole or in part by an occupational therapy assistant (OTA). Use of these modifiers will begin on Jan. 1, 2020, with payment reductions beginning in CY 2022. CMS also finalized a definition of “in whole or in part” as visits during which more than 10 percent of the therapy service is furnished by a PTA or OTA.
In this rule, CMS proposes to make the 10 percent calculation based on the respective therapeutic minutes of time spent by the therapist and the PTA/OTA, rounded to the nearest whole minute. CMS proposes two approaches for this 10 percent calculation for visits involving both therapist and assistant services:
The total time for a service would be the total time spent by the therapist (whether independent of, or concurrent with, a PTA/OTA) plus any additional time spent by the PTA/OTA independently furnishing the therapeutic service.

• For example, in the case of therapy being delivered concurrently – if a therapist spent 60 minutes providing neuromuscular re-education (97112) to a patient, but during that session they required the side-by-side assistance of an assistant for 7 minutes, the entire hour of neuromuscular re-education would subject to the 15 percent therapist assistant adjustment, since 7 minutes exceeds 10 percent of the total 60-minute service time. This means that CMS is proposing that when a therapist is furnishing care and requires the help of a therapist assistant for safety or effectiveness purposes, for payment purposes, the therapist’s time is ignored, and this treatment time is instead attributed to the therapist assistant 15 percent payment adjustment policy.
   
• Or, in the case of the therapist and assistant each separately, exclusive of each other, furnishing minutes of the same service, in different time frames – If a therapist spent 20 minutes furnishing therapeutic exercise (97110) and the assistant spent 25 minutes furnishing the same service, therapeutic exercise (97110) – the entire 45 minutes of the service would be subject to the 15 percent therapy assistant adjustment, since 25 minutes exceeds 10 percent of the total 45-minute service time. The proposed application of the 10 percent standard when the therapist assistant and the therapist each separately furnish portions of the same service is in direct conflict with CMS’s response to comments in the 2019 PFS final rule in which the agency outlined its policy regarding application of the modifier when therapist and therapist assistant furnished portions of the same service, in that it allowed the billing of the same procedure code on two different claim lines as long as there is a different modifier used to uniquely identify the service.
   
• In addition, the agency proposes additional documentation requirements for therapy coding and billing to explain why the new CQ/CO modifier was or was not applied to the claim for each service furnished that day. In other words, CMS is proposing that the outpatient therapy provider would be required to add a statement in the medical record for each line of every claim to explain why this modifier was used or not used.
   
• A template letter that responds to the above proposed policy will be available on APTA’s Regulatory Issues: Take Action webpage within the coming days. Keep in mind that your comments do not represent the association; they represent you as an individual physical therapist, physical therapist assistant, or student.

Though APTA has submitted their concerns directly, we encourage members and nonmembers to provide their individual feedback, as these perspectives are critical to policy development. APTA is developing talking points for members to submit concerns to CMS through their Take Action site.