Grassi Healthcare | EAlert: Outpatient Rehab Therapy Changes
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Healthcare Leadership Team

EAlert: Outpatient Rehab Therapy Changes

Both the Bipartisan Budget Act of 2018 and the CMS Proposed Final Rule bring changes to Outpatient Rehabilitation Therapy services.

In February, Congress passed the Bipartisan Budget Act of 2018 (“The Act”), which contained many provisions that extended various Medicare FFS policies and recommended other changes. One of these changes related to permanently discontinuing therapy caps was subsequently enacted retrospectively to January 1st, 2018. While the caps were discontinued, the provision continues to require the KX modifier as an attestation of medical necessity when the services exceed the prior cap threshold. The $3,000 medical review process threshold was also retained.
What providers may not be aware of:
One of the changes proposed for the MPFS final rule for CY 2019, is a fee schedule payment reduction to outpatient therapy services when rendered after January 1, 2022 by a Therapy Assistant (PTA/OTA). The reimbursement reduction would be 85% of the amount of payment AND; in order to identify these services, establishes a modifier to delineate therapy assistant services when furnished in whole or in part (any minute of the outpatient therapy service that is therapeutic in nature) of a therapy service. The modifier change will be effective January 1, 2020 with voluntary reporting in CY 2019 regardless of whether a payment reduction is in place. Included in the modifier change will be revisions to the current PT/OT/SLP modifier descriptions.
Now the good news!
The proposed rule also includes a provision to end the requirements for the reporting and documentation of functional limitation G-codes (HCPCS codes G8978 through G8999 and G9158 through G9186) and severity modifiers (in the range CH through CN) for outpatient therapy claims with dates of service on and after January 1, 2019. The functional reporting became effective January 2013, as a part of the Middle Class Tax Relief and Jobs Creation Act (MCTRJCA) of 2012 and required CMS to implement a claims-based data collection strategy to collect patient functional data over the episode of therapy care, to facilitate a better understanding of therapy outcomes. The data collection required the reporting of certain HCPCS G-codes and companion modifiers at various points in time during the course of treatment. Many factors, including CMS and commenters data analysis of episodes of care since 2013, resulted in information not compelling enough to be used as a basis of payment reform. The consensus of commenters who responded to the CMS RFI on burden reduction was that the requirements for outpatient therapy services are overly complex and burdensome. CMS agreed with commenters and noted that section 3005(g) of MCTRJCA was not codified into the Act, did not specify how long the data collection strategy should last, and did not believe it was intended to last indefinitely. The conclusion was to propose a revision to end the reporting requirements.
For more information, contact Stephanie Fiedler, Director, Revenue Advisory Services at Grassi Healthcare Advisors, LLC, at