Post-Acute Care is in a season of change.  In the Skilled Nursing Facility, we are facing a lot of change in the next year.

First, while we are all preparing for PDPM, we need to take some time to review the Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019 that was released on November 1, 2018.

Let’s first start by rejoicing that Functional Limitation Reporting is going away!  That’s right folks! G-codes and Severity Modifiers, which identified functional limitations in outpatient therapy, will no longer be required on therapy claims for services furnished on or after January 1, 2019!

Not so good news, Outpatient Physical Therapy and Occupational Therapy Services Furnished by Therapy Assistants effective January 1, 2022 will be reimbursed at 85% of the applicable Part B payment amount.  This is required by The Bipartisan Budget Act of 2018. CMS must establish a new modifier by January 1, 2019. Therefore, CMS is currently finalizing the establishment of two new “payment” modifiers: one for Licensed Physical Therapist Assistants (LPTAs); one for Certified Occupational Therapy Assistants (OTAs).  These new “payment” modifiers will be required on all therapy claims beginning January 1, 2020 when the therapy services are provided in whole or in part (more than 10% of the service) by a LPTA or COTA. These two new “payment” modifiers denote that the services were provided by a LPTA or COTA and must be recorded along with the current PT and OT modifiers.

Quality Payment Program proposed changes goal is to reduce caregiver burden to focus on outcomes and promote interoperability of electronic medical records. These changes are intended to reduce process-based quality measures that are low-value or low-priority in order to focus on meaningful measures that have more of an impact on outcomes.  By promoting interoperability performance to support electronic medical records and patient access to their records, this will align the performance category for providers in the hospital setting.

Practice Expense (PE)- Market-Based Supply and Equipment Pricing Update: CMS is finalizing their proposal to phase-in use of new prices for supplies and equipment over a four-year period beginning in calendar year 2019 to ensure a smooth transition.

Conversion Factor Update: With the budget neutrality adjustment to account for changes in RVUs, all required by law, the final 2019 PFS conversion factor is $36.04, a slight increase above the 2018 PFS conversion factor of $35.99.

Other payment provisions include:

  • Streamlining Evaluation and Management Payment and Reducing Clinician Burden;
  • Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based Services;
  • Comment Solicitation on Creating a Bundled Episode of Care for Management and Counseling Treatment for Substance Use Disorders;
  • Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder and Other Substance Use Disorders;
  • Providing Practice Flexibility for Radiologist Assistants;
  • Payment Rates for Non-excepted Off-campus Provider-Based Hospital Departments Paid Under the PFS;
  • Medicare Telehealth Services;
  • Clinical Laboratory Fee Schedule;
  • Ambulance Fee Schedule Payments;
  • Recognizing Communication Technology-Based and Remote Evaluation Services for Rural Health Clinics and Federally Qualified Health Centers;
  • Wholesale Acquisition Cost-Based Payment for Part B Drugs: Finalizing a Reduction of the Add-on Amount;
  • Medicare Shared Savings Program (Shared Savings Program) Accountable Care Organizations (ACOs);
  • Request for Information on Price Transparency; and
  • Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging

For more detailed information, please visit the CMS Newsroom.

Gina Tomcsik
Director of Compliance and Regulatory Strategy