Thank you for your efforts during this year of successful advocacy!
HIGHLIGHTS OF SUCCESS
Repeal Therapy Cap
In February 2018, after 20 years of advocacy and grassroots engagement we repealed the arbitrary per-beneficiary therapy cap on outpatient rehabilitation covered by Medicare, effective January 1, 2018. For CY 2019, the KX modifier will need to be applied to claims upon reaching $2040 in spending. By applying the KX modifier to the claim, the therapist or therapy provider is confirming that the services are medically necessary as justified by the appropriate documentation in the medical record. Should the KX modifier not be used appropriately, claims could be denied. Until 2028, claims exceeding $3000 for combined spending for PT and speech-language pathologist (SLP) services, and $3000 for stand-alone OT services are subject to targeted medical review; however, not all claims exceeding the threshold will be subject to review as they once were.
Functional Status Reporting Requirements for Outpatient Therapy are Discontinued
Since January 2013 all providers of outpatient therapy services have been required to include functional status information on claims for therapy services. This November, the Center for Medicare and Medicaid Services (CMS) decided that due to the repeal of the therapy cap and stakeholder input arguing against the burden of reporting, the requirements for the reporting and documentation of functional reporting status for outpatient therapy claims will be eliminated for services furnished on or after January 1, 2019.
Merit-Based Incentive Payment System (MIPS)
Effective for reporting year 2019 and payment year 2021, physical therapists have been added to the list of Medicare-eligible providers who could be required to participate in MIPS. Recognizing that low-volume providers such as private practice physical therapists will have difficulty participating in MIPS, CMS established three separate criteria under which a MIPS-eligible clinician could claim a low-volume threshold exemption. Clinicians or groups are not obligated to participate in MIPS if any of these three thresholds apply to them:
1. If they have less than $90,000 in Part B allowed charges for covered professional services;
2. If they provide care to 200 or fewer Part-B enrolled individuals who are furnished MPFS services; or
3. If they provide 200 or fewer covered professional services under the MPFS. A professional service is considered to be a billed unit of service.
At the same time, CMS seeks to encourage even small volume providers or group practices to participate, so starting in Year 3 clinicians or groups would be able to opt-in to MIPS if they meet or exceed at least one but not all, of the low-volume threshold criteria.
While supporting efforts for the Medicare Telehealth Parity Act (H.R.2550) as well as the tailored approach of expanding coverage for telehealth by way of the CONNECT for Health Act (H.R.2556/S.1016), we achieved passage of two provisions of the CONNECT for Health Act. The first grants Medicare Advantage plans the authority to expand their basic benefit coverage to include reimbursement for telehealth services and the second (FAST Act (H.R.1148/S.431)) allows for the use of telehealth to assess strokes regardless of patient’s geographic location. These wins will provide us a solid foundation upon which to build in the 116th Congress.
GETTING READY FOR THE 116TH CONGRESS
The new members of the 116th Congress will be sworn in on January 3, 2019. In the House of Representatives every member of the Chamber will be sworn in—both new members as well as those who won re-election. In the Senate the one-third of members whose seats were up for re-election will be sworn in on January 3rd. Additionally, Martha McSally (the candidate for the 2018 Arizona senate race who did not win on November 6th) has been appointed by the governor of Arizona to fill the remaining two years of the deceased Sen. John McCain’s term. McSally will also be sworn in on January 3rd.
In the House of Representatives
In the 2018 midterm general election, Democrats won 235 seats and Republicans won 199 seats. As a result, the Democrat will make the most of their sizable majority in the House for the 116th Congress by bringing up and introducing bills on issues that were sidelined this past Congress. On January 3rd all of the Members of the 116th Congress will elect a Speaker of the House. Since the Democrats will be the majority party, the position Majority Leader will be held by a Democrat and the position of Minority Leader will be held by a Republican. After many internal negotiations which included leadership term limits, Nancy Pelosi (D-CA-12) won the internal, member-elect Democrat-only election in November. As a result, it is widely expected that she will clinch the Speaker of the House election. The Majority Leader is expected to be long-time number two Steny Hoyer (D-MD-5). Former Speaker of the House Paul Ryan (R-WI-1) did not run for re-election, so his long-time number two, Kevin McCarthy (R-CA-23) is expected to be Minority Leader.
We will have a lot of work to do to educate the new members of Congress and their staff about the value of physical therapy. For this year-end edition, there are no assignments, but you will hear from me in the new year with ideas and opportunities for engaging with your legislators.
Thank you for your continued advocacy and for a great 2018!
For one-pagers, talking points, and information on PPS’s legislative priorities and activities, visit the Advocacy section at www.ppsapta.org