The Final Rule, published by CMS on November 23, 2018, addresses several items that will affect the treating therapist, whether in outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies, or comprehensive outpatient rehabilitation facilities.  The information below focuses on just 1 parcel of information and updates within the Final Rule.

Outpatient Therapy Services (This is you Medicare Part B)

Unless you live under a rock, you have probably heard that the Medicare Part B therapy caps and the exceptions process have been repealed.  This allows for more appropriate provision of therapy, as/when needed, to keep our residents healthy and mobile for longer.  This does not mean that we no longer have to track Med B dollar amounts in the given year.  The KX modifier (this is a billing code placed on the billing form to note that the cap amount has been exceeded) still needs to be added when the patient’s Medicare part B charges have exceeded $2040 for PT and ST combined and $2040 for OT (updated amounts for 2019).  The KX modifier serves as an attestation from the therapist that services are medically necessary as justified by appropriate documentation in the medical record.  For patients receiving services above these amounts, claims without the KX modifier attached will be denied.  Also continuing is the targeted medical review (MR) process at a threshold of $3,000 in services claims ($3000 for PT and ST combined and $3000 for OT).  CMS provided no further guidance on targeted review.

The next item the final rule addresses of interest is the provision of PT and OT services by a therapy assistant.  The new statute sets payment for these services at 85% of the normal Part B payment for those services, effective for CY 2022.  Beginning as early as sometime in 2019, CMS has stated they would allow providers to start reporting on services provided by assistants.  Providers must begin using the new modifiers on January 1, 2020, although payment cuts will not begin until January 1, 2022. There will be the addition of a modifier on the billing form to denote if all or a portion of the visit was provided by a PTA or OTA.  The modifiers will be in addition to the existing GO and GP modifiers and are CQ for PTA and CO for OTA.  We await further details on this.

And finally, last but not least for this part of the Final Rule is the discontinuation of Functional Limitation Reporting.    “CMS understands that the current functional reporting requirements (i.e., non-payable G codes) are a burden for providers of outpatient therapy services, and as a result the agency proposed to end functional status reporting in the proposed rule.  CMS finalized this proposal in the Final Rule; therefore, beginning on January 1, 2019, providers will no longer need to report codes G8978 through G8999 and G9158 through G9186.  In addition, providers will also not need to report severity modifiers CH through CN on outpatient therapy claims with dates of service on or after January 1, 2019.” (NASL) What this does not discontinue is the requirement for a therapist (not assistant) to provide care-at least one unit of treatment, and complete a progress report a minimum of every 10th visit.

There is much, much, much (did I say much?) more stimulating and exciting information to be found in The Final Rule-2500+ pages of government whimsy…including information on updates and changes to telehealth services, payment updates to the most used codes by therapists, the Quality Payment Program (QPP) and more.  The information above is meant only to give a brief and simplified update of a portion of what CMS’s Final Rule for 2019 covers.  To read the document in its entirety, you can click the link:  https://federalregister.gov/d/2018-24170

Jennifer Callahan
Clinical Operations Specialist