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  • Writer's pictureDaniel Puskin

Hey CMS! What’s Next?

Telehealth for PTs is gaining momentum

What CMS chooses to do in the coming months matters, and probably not just for Medicare recipients. After all, so many private payers follow their lead. So, what is CMS thinking?

This linked article by experts Leah Dillard, Rachel Shapiro, and Kevin Van Dyke from policy evaluation firms IMPAQ and AIR lays out the past, present and potential future for CMS’s approach to billing for telehealth services. Temporarily, therapists, occupational therapists and speech pathologists can be reimbursed for telehealth services. In the past, they were not considered telehealth providers by Medicare and thus were not eligible to bill for care. The article also looks at the proposed Medicare Physician Fee Schedules for 2021 and its implications for how telehealth services (and PTs overall) are reimbursed beyond the fall of this year.

What’s happening now in telehealth?

In the fee for service market, telehealth has typically not been reimbursed by insurers. The exception is underserved areas, especially in rural areas. The technology continues to evolve and become more viable for home use. Yet, just 0.1% of all primary care visits under Medicare were conducted virtually during February. The recent public health emergency (PHE) dramatically changed that dramatically.

"Telehealth usage exploded, especially in the first couple months of the emergency. During mid-April, well over 40 percent of Medicare primary visits were via telehealth."

Through the CARES Act, CMS and private payers suddenly allowed for a wide array of health services to be provided virtually. Telehealth usage exploded, especially in the first couple months of the emergency. During mid-April, well over 40 percent of Medicare primary visits were via telehealth. While usage has tailed off, the knowledge gained by practitioners and patients remains, and at least temporarily so do the reimbursement policies by Medicare and insurance companies.

What are those reimbursement policies during the public health emergency?

  1. Generally, a wider range of telehealth services are being reimbursed by Medicare. Of particular interest to physical therapists, PTs, OTs and speech pathologists can be compensated for their services at rates equal to in office visits.

  2. Audio visits can now be billed

  3. Non-synchronous treatments can be more widely billed

  4. First encounters are now covered by Medicare (this began before the PHE)

  5. Supervision can occur virtually

What's next for telehealth? The 2021 Physician Fee Schedule could be bad news for telePT.

The Administration is weighing different options as is Congress, indicating there appears to be some momentum for fairly extensive lasting change. Yet, without further action, the inroads for telehealth and telePT in particular are in jeopardy.

Bottom line, the forecast is that the temporary codes expanding Medicare reimbursement for PTs (plus OTs and Speech Pathologists) are expected to go away at the end of the PHE. Geographic licensing, site, and technology restrictions (no audio only) are expected to return as are the practitioners who are allowed to bill for PT services under Medicare.

Many have advocated for making the changes more permanent including geriatric focused academics, physical therapist practice company alliances (APTQI) and Physical Therapist providers (APTA).

Yet, what happens if the emergency continues well into 2021? What about into 2022? It might be hard to roll back once the digital horse has left the barn. CMS has solicited comments from affected providers on what temporary codes should be allowed to be permanent.

The 2021 Physician Fee Schedule could be bad news for PTs overall

"Overall, this is expected to translate to approximately 9% less in payments from Medicare for PTs"

Of more immediate focus to PTs are the proposed changes in reimbursement by CMS. Overall, the profession sees this as a significant loss. There were more than 25,000 letters to CMS as of Oct. 5 in response to the proposed cuts. The expected loss in Medicare based payments for PTs is expected to be 9%.

Yes, there is good news for PT professionals about the new Fee Proposals:

  • Credited units for evaluation services are expected to rise by 28 percent. A breakdown on the proportion of care for the elderly that is evaluation based would be good to explore in the future. These shifts in reimbursement formulas may change those proportions.

  • Additionally, Physical Therapist Assistants will now be able to deliver manual therapy and be reimbursed at 85% the rate of PTs starting in 2022 (which should allow for more flexibility in the delivery of care for practices).

  • Merit-Based Incentive Payment System (MIPS) for higher volume Medicare billers attempts to incentivize innovative and cost effective care. Providers will ultimately be evaluated each year on a scale of 0-100 based on quality, improvement, promoting interoperability of care, and cost. MIPS thresholds are easier to meet during the pandemic than they would have been otherwise (50 points rather than the 2021 scheduled 60 points threshold). This means in later years, participants will be eligible for higher adjustments on provided services.

Overall, PT professionals are very concerned about the new fee proposals:

  • At this point evaluation services are not a huge part of PT services under Medicare. Medicare reimbursement per unit of PT care is expected to drop by 10.61% . The conversion factor per unit of care was cut by $3.83, down to $32.2605. Overall, this is expected to translate to approximately 9% less in payments from Medicare for PTs.

The clock is ticking with the fee proposals

Because of budget neutrality rules where evaluation and management type services' increased reimbursement means other treatments must be cut, inevitably some specialties will win out and others see cuts. APTA is pushing for a relaxing of these neutrality rules (especially during the public health emergency). With just over 3 months until these compensation rules will kick in, APTA is looking for legislative remedies to counter with a solution for the E/M cuts including a bipartisan sign-on letter that proposes waivers of the neutrality rule.

Questions to think about or discuss in the comments:

  • What is the resistance to telePT amongst policy makers?

  • What evidence would telePTs need to present to convince lawmakers to incorporate some of those codes? Which codes have a better chance of being incorporated?

  • How long does the pandemic need to last for more telePT services to be covered permanently?

  • What do you expect will happen with private payers during all of this? Could they lead without CMS action?

  • How does telePT fit into MIPS requirements/incentives?

  • Is parity a good thing for Virtual PT or will it make insurers less willing to allow experimentation with it?

  • How much do we expect PTs to shift towards more evaluation and less of the other PT services if the Physician Fee Schedule changes go forward? How fungible is this? Especially given the ability to shift some of the therapy PTAs.

  • The budget neutrality makes reimbursement formulas a zero sum game. “Robbing Peter to pay Paul” so to speak is how APTA Vice President of Government Affairs Justin Elliot puts it. What would be the actual impact on earnings in the profession? What are other disciplines scheduled to experience cuts doing?

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