Learn more about the final 2022 CMS fee schedule and how it relates to PTA reimbursement.
Much like every final rule from the Centers for Medicare & Medicaid Services (CMS), the 2022 final fee schedule wasn’t exactly unexpected. With some elements initially implemented in 2018, and others cited in the proposed rule over the summer, Medicare changes for physical therapy were a long time coming — especially updates to physical therapy assistant (PTA) reimbursement in 2022.However, that doesn’t mean that recent changes to the physical therapy fee schedule aren’t confusing. On the contrary, the newly imposed PTA Medicare cuts may still come as a surprise to some practices, or even cause complications for billing. To better understand how the final fee schedule could impact your practice, take a look at updates to PTA reimbursement in 2022.
In November 2021, CMS released itsfinal 2022 Physician Fee Schedule (PFS), which specified updates to several therapy sectors. First, CMS confirmed a 1% reduction of Medicare Part B physical therapy and occupational therapy rates. While an unwelcome change, this reduction is a slight improvement from the 2% cut the organization originally proposed in July 2021.Another payment differential that’s taken effect under the final fee schedule is the 15% payment reduction for physical therapy and occupational therapy services provided “in whole or in part” by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs). In situations where more than 10% of a 15-minute unit timed code PT or OT service is furnished by an assistant, CQ and CO modifiers will now trigger a 15% reduction.The last major change for therapy providers has been an amendment to telehealth services under Medicare Part B. CMS has now stated that PTs OTs, SLPs, PTAs, and OTAs are eligible providers of telehealth services for the duration of the COVID-19 Public Health Emergency (PHE). CMS has also extended certain therapy services — including various PT, OT, and speech codes — to the Medicare telehealth services list through December 31, 2023, on a Category 3 basis.
When Congress passed the Bipartisan Budget Act in 2018, it directed CMS to establish a payment differential for services providedin whole or in partbyphysical therapist assistantsandoccupational therapist assistants. This payment rate is 85% of the rate physical therapists and occupational therapists are paid, as indicated by claims modifiers.However, the original legislation did not clarify what exactly “in part” meant. Exactly how much of the care was considered “in part?” Well, the 2022 ruling adheres to thede minimis standardestablished in the 2019 Fee Schedule, which defines “in part” as when the minutes of the portion that is provided by the assistant exceed 10% of the total minutes for that service or unit of service.The modifiers CQ for PTAs and CO for OTAs must be attached to services 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. However, if a therapist and an assistant treat a patient together, meaning the assistant is the second pair of hands during treatment, then the modifier does not apply.The payment differential and use of the CQ and CO modifiers apply to all private practice, hospital outpatient departments, comprehensive outpatient rehabilitation facilities (CORFs), skilled nursing facilities (SNFs), home health agencies, and rehabilitation agencies. These modifiers, as well as updates to PTA reimbursement 2022, do not apply to Critical Access Hospitals.
While CMS’s clarification of “in part” services was welcomed, many providers had questions regarding how it was to be calculated and for what services specifically. Fortunately, the final fee schedule has included more detail on physical therapy assistant reimbursement.
Another common scenario surrounding PTA reimbursement in 2022 is when a therapist provides some part of care, and then an assistant takes over and provides the rest of the care for that visit. Any time the care of the PTA exceeds the 10% rule, you must add the CQ modifier. These modifiers have been finalized and went into effect on January 1, 2022, including the PTA Medicare cuts.
While PTAs aren’t being “phased out,” recent changes to the physical therapy fee schedule created a 6% cut in payments for physical therapy services with an additional 15% deduction from therapy assistant services. Combined, PTAs can expect to be paid 21% less in 2022 than they were in 2020.So, though PTA Medicare cuts are not an effort to phase out assistants, providers should anticipate that services furnished by a PTA will induce pay cuts in 2022. Changes to physical therapy assistant reimbursement will mean different things for each practice, but in general, providers may want to reconsider how patient services are allocated to their staff.
In the 2022 physical therapy fee schedule, CMS provides further clarification on how to calculate the 10% limit. They provide two 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 the 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 minimum 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.
Let’s take this to some real-life examples, like if a PT/PTA sees a patient and provides 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 is subject to the modifier.
CMS first introduced payment modifiers in 2018 and asked rehab therapists to begin using them by 2020. Now, the actual payment differentials have taken effect on January 1, 2022. Modifiers should be applied on a per-code basis and should be included in the claim when billed. As a refresher, this means your claims should state something like:
If the services provided were only provided by the PT/OT then you would note: Code XXXXX CQ/CO – NA
Medicare continues to implement changes to catch up with legislation. There will be substantial financial, operational, and compliance impacts to remain wary of throughout the 2022 calendar year.MWTherapyprovides a full suite of physical therapy software tools to keep your finger on the pulse of all aspects of your practice, including Medicare’s ever-changingcompliancerequirements.
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