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2020 Medicare Changes for PTA & OTA Modifiers/Reimbursements

Physical Therapy Assistant/Occupational Therapy Assistant
Billing Modifiers & Reimbursement – Substantial Changes Proposed for 2020

The 2020 CMS (Centers for Medicare & Medicaid Services) proposed rule has been released. This is the first chance that we all have to see what CMS is planning for next year. One of the biggest changes proposed is to PTA/OTA billing policies. This change will impact the modifiers you use and ultimately the reimbursement that you receive for services provided by PTAs/OTAs. This change was first discussed in last year’s rule but there were many questions then and some of the 2019 rule was held off. CMS is attempting to provide some additional clarity in this year’s rule but, in doing so, potentially creating more requirements.

This is a proposed rule, it is subject to change. Typically the final rule is published in November, or so. This blog post is an interpretation of the proposal. It will not be finalized until later in the year.

What is this all about?

You may be aware when Congress passed the Bipartisan Budget Act in 2018 it directed CMS to establish a payment differential for services, provided in whole or in part, by physical therapist assistants (PTA) and occupational therapist assistants (OTA). This payment rate is 85% of the rate physical therapists and occupational therapists are paid. Well, CMS finalized the rule actualizing that legislation last year putting it into effect beginning January 2020.

The original legislation did not clarify what services that are provided “in part” meant. Exactly how much of the care was considered in part? Subsequently, in the 2019 final rule CMS clarified, noting that any care that exceeded 10% of the total time of care fit the “in part” definition and would be subject to the reduced billing. Also in that ruling CMS instructed that new modifiers, CQ for work provided by PTA’s and CO for work provided by OTA’s would need to be attached to those services, as listed on the claim, exceeding the 10% time threshold. These modifiers are to be included on the claim on the same lines where any GP or GO modifiers are provided (basically any physical therapy or occupational therapy code).

The payment differential and the use of the CQ (PTA)/CO (OTA) modifier applies to all private practice, hospital outpatient departments, SNF’s, CORF’s, Home Health Agencies, and Rehabilitation Agencies. It does not apply to Critical Access Hospitals.

When and where do these apply?

While CMS’s clarification of “in part” services was welcomed, APTA and others still had questions regarding how it was to be calculated and for what services specifically. Last month CMS issued a proposed rule with more clarification on these PTA and OTA modifiers. First, these codes are only provided for time spent providing therapeutic services, not any administrative or non-therapeutic tasks. Therapeutic services include all timed and untimed coded procedures and modalities including initial evaluations and re-evaluations.

Secondly, they need to be applied for any care provided solely by the PTA or OTA. So, all Medicare patients, whose entire care for any visit is done by a PTA or OTA, need these CQ or CO codes applied to all codes billed for that date of service.

Thirdly, they state the modifier codes will need to be applied when any portion of concurrently provided care that exceeds the 10% time requirement. This means for any visit where the PT and the PTA provide care simultaneously then any minutes of care provided by the PTA exceeding 10% of the total time of care is subject to the modifier.

Another scenario is if the OT provides some part of the care then the OTA takes over and provides some part of the care for that visit then any time the care of the OTA exceeds the 10% rule then you must add the CO modifier.

If this rule becomes final, you would be required to begin applying these modifiers where applicable on January 1, 2020. The change in reimbursement would begin with visits on or after January 1, 2022.

Examples

In the proposed rule CMS provides further clarification on how to calculate the 10% limit. They provide 2 possible methods:

Method #1. Divide the number of minutes of care provided by the PTA/OTA by the total minutes of care provided then multiply by 100. That gives you the percentage of time of care provided by the PTA/OTA. You are to round to the nearest whole number. CMS says anything equal to or greater than 11% requires application of the modifier.

Method #2. Simply divide the total time of care provided to the patient by 10 (round to the next whole integer) and add 1 minute to set the minimal time requirement. So if the treatment was 60 minutes total then 10% is 6 min + 1 is 7 minutes. If the PTA/OTA care was 7 minutes or more then the CQ/CO modifiers are added to those line items.

Here is a chart that CMS provides with examples of Method #2

More Examples

Let’s take this to some real life examples. If the PT/PTA sees a patient and provide a total of 45 minutes of care. That means 10% of 45 is 4.5 minutes. You would round this to 5 minutes and that becomes your 10% benchmark. Any care provided by the PTA on that visit totaling more than 5 minutes requires the modifier and will be paid at the differential rate.

Likewise if the PT is seeing a patient for the initial evaluation and the PTA gathers some of the evaluation data, like ROM or administers a Berg Balance Scale then the total PTA time is to be considered in the same way as above. If the evaluation takes 50 minutes then the 10% threshold is 5 minutes and any care provided by the PTA totaling 6 minutes or more are subject to the modifier.

But there is more…new documentation requirement

Also beginning January 2020 CMS is proposing that the documentation provide a short description of the application or non-application of the CQ/CO Modifiers. Keep in mind that modifiers are applied on a per code, basis, and should be included in the claim when billed. This means you would need to state something like:

Code 9XXXX CQ/CO code applied: services fully provided by PTA/OTA
or:
Code 9XXXX CQ/CO code applied: PTA/OTA services provided 15%
or:
Code 9XXXX No CQ/CO code applied: PTA/OTA services provided less than 10%.

If the services provided were only provided by the PT/OT then you would note:
Code 9XXXX CQ/CO – NA

CMS is also soliciting feedback if the documentation requirement should go beyond this to require the actual documentation of the total time and the time spent by the PTA/OTA. To be clear these documentation requirements are proposed only at this point. A final rule will likely be issued in this fall.

It's important to make your voice heard

CMS is soliciting comments on whether these new requirements (particularly the documentation requirements) will create a significant administrative burden. According to posted information, APTA appears to take issue with various aspects of the proposed rule and will be working with CMS to address concerns. You have an opportunity to register your own concerns on this issue through the APTA Regulatory Action Webpage or directly through the Federal Register and should do so if you are concerned. The more comments CMS hears the more likely they are to consider changes. CMS will accept comments on the proposed rule until September 27th, 2019.

You must also become very familiar with these rules so you are ready for implementation in January. If you have PTA’s or OTA’s in your practice you should know exactly how they operate so you understand how these changes will impact your practice.

Some useful resources:

The bottom line

Medicare is making changes to catch up with legislation. There will be substantial financial, operational and compliance impacts that you need to start preparing for. In addition, your advocacy can help in letting CMS know if you feel that these changes are overly burdensome to your practice. MWTherapy provides a full suite of physical therapy software tools to help you with all aspects of your practice, including keeping up with Medicare’s ever-changing compliance requirements.

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