CMS Issues Final Rule for Services Paid Under the MPFS & MIPS for PT and OT
On November 1, 2018, the Centers for Medicare and Medicaid Services (CMS) issued the 2019 final rule for services paid under the Medicare Physician Fee Schedule (outpatient PT, OT and SLP services) as well as the Merit-Based Incentive Payment System (MIPS) for physical therapists, occupational therapists and speech-language pathologists in private practice.
Highlights of the Final Rule include:
- 2019 Conversion Factor
- 2019 Therapy Threshold Dollar Amount
- 2019 Targeted Medical Review Dollar Amount
- Functional Limitation Reporting for 2019
- New Modifiers to Distinguish Services Provided by a PTA or OTA
- “In Whole or In Part” Defined of a PTA or OTA Service
- 2019 MIPS for Physical Therapists, Occupational Therapists and Speech-Language Pathologists
2019 Conversion Factor
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Thank you for sharing this information and being a great resource.
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Rick, regarding the Functional Limitation Reporting coming to the end – is that the functional G codes that we submit on eval and every 10th visit?
What is the threshold for MIPS? Is it an annular dollar amount, visit limit or # of lives?
None of what you mentioned. I will be doing a webinar on MIPS on December 18th from 1:00pm – 3:30pm where I will answer many questions about MIPS. I will also be writing several article on MIPS in the coming weeks.
Rick, Will hospital based outpatient therapists be required to participate in MIPS in 2019?
MIPS applies to practices that submit claims on a 1500-claim form.
Can Clarify the Functional limitations reporting for 2019?
so we do NOT need to report for require med B and only supplemental medical insurance?
FLR is ending for traditional Medicare. You will have to check with Medicare Advantage plans and other insurance carriers to determine if they will continue with FLR.
For practices over 15 eligible providers ( PT, OT and ST) will they be able to report the MIPS data via claims?
We are a private practice that does not participate with Medicare or Medicaid, so will we be required to participate in MIPS, or not? Thank you
MIPS applies only to traditional Medicare Part B. If you do not participate with Medicare, then you can’t participate in MIPS.
Hi Rick, thanks for the great info as always. can you tell me if they have finalized the rule to remove the Functioning reporting as of 1/1/19, or are we still waiting for confirmation. thanks Kim
That answer is in this article.
Are CAHs exempt from the PTA and COTA services payment reduction? I recall seeing that information somewhere but have not been able to locate it since. Thank you!
You are correct. You can read about it on page 638 of the final rule.
Hi Rick- thanks for condensing this information for us. Trying to read through the final rule itself challenging! In regards to FLR: will you clarify what it means that “Medicare is finalizing their proposal to end FLR”. Does that mean that more details will be forthcoming?
In July, CMS proposed to end FLR effective January 1, 2019. In the final rule released on November 1, 2018, CMS finalized (confirmed) their proposal to end FLR. FLR for traditional Medicare Part patients is ending at the end of 2018.
Rick, Thanks for your expertise. Will Functional Level reporting be required to close out the ones opened in 2018?
Last date of service to report G-codes on a claim form for traditional Medicare Part B is December 31, 2018. No G-codes required after that.
Great summary as usual Rick. Thank you.
In the proposed rule, I believe the modifiers being suggested for use when the patient was treated by an assistant could be used on a voluntary basis beginning sometime in 2019, but would be required beginning with dates of service on and after January 1, 2020. Is this still a possible option for 2019?
It was never an option for 2019. The new modifiers will be required beginning on January 1, 2020.
Will the 15% payment reduction for PTA/OTA be on top of the MPPR rate, if applicable?
Hi Rick. Thank you for providing these valuable updates. If billing via a UB-04 form (hospital-based) for outpatient PT/OT/Speech, will issuance of an ABN be required in any situation given the Final Rule for 2019?
There are many situations when an ABN may be required for providers who bill on a UB-04 claim form.
Please check out my FAQs on the ABN at http://gawendaseminars.com/faqs/abn/
Also, check out this article I wrote on October 29, 2018.
Perfect! Thank you.
Hi Rick, can you clarify a point about FLM reporting going away in Jan 2019? In the final rule it states that they are retaining the codes until CY 2020, is that so those who need to report for billing have time to switch over? We are transitioning to a new EHR next year and are trying to determine if we need to keep the G-codes for FLM. Thanks for your information!
FLR is no longer required for traditional Medicare Part B patients effective January 1, 2019. The FLR g-codes will still remain since they are tied to the 7 FOTO measures that are applicable to MIPS.
Many of our commercial Medicare products (e.g. Medicare + Blue) have a standard line regarding therapy coverage: “follow medicare guidelines”. This was helpful as it indicated we were to follow therapy cap and FLR g-code requirements. Will that same phrase now mean no FLR g-codes required? Do you think they are that ‘in-step’ with Medicare?
Just because a Medicare Advantage (MA) plan stated they “follow Medicare guidelines” did not mean they had a therapy cap, required signed plans of care, required FLR, etc. In fact, most did not have a therapy cap, did not required signed plans of care and did not implement FLR. If a MA plan did implement FLR, you would have to check with them to see if FLR is going away in 2019 or not.
Does the 2019 fee schedule apply to all those who bill for Part B therapy services? I get confused as to if this applies to CORFs and ORFs (rehab agencies) or only PT/OT/ST in private practice and Therapy group practice. Do all these “environments” get paid similarly? Any resources to look into this? Maybe I should restructure to be an ORF. Thanks.
The rates are the same for all outpatient therapy settings for Part B therapy services paid under the Medicare Physician Fee Schedule.
Hi Rick- I wanted to confirm (as noted in 9/17 MIPS article) there is no change and if you bill on a UB-04 you are not eligible to participate in MIPS? Thank you!
MIPS applies to private practices. You know if you are a private practice under the Medicare program because you submit your claims on a 1500-clai form.
Rick was there any mention if payment would be made for the cognitive code 97127, or would we still need to use the G0515 code?
The Medicare program will still use G0515 in 2019.
So individual providers need to exceed $97K to qualify for MIPS? This is what I am hearing from my EMR system.
There are 3 thresholds individuals need to exceed during the determination period to be required to participate in MIPS. If they exceed 1 of the 3, they can opt-in to MIPS. Watch for MIPS FAQs beginning next week and I highly recommend our 2.5 hour webinar on MIPS on December 18, 2018.
Thanks for answering my last question. Also wanted to ask, Do we report MIPS quality measures just at evaluation and re-certification? Thanks.
It depends upon each measure when it gets reported and how often it gets reported. I will be discussing all this in great detail during our MIPS webinar on December 18, 2018.
Just thought of another question. With the new therapy modifiers for PTAs and COTAs, will we start reporting those in 2019 or not until the rate reduction comes into play in 2022? Thanks again.
Please read the article for your answer.
We bill on the UB-04 form so are not eligible to participate in MIPS but does that mean we will be subject to payment reductions since we are not participating in the MIPS program
The payment adjustments, both positive and negative, only apply to MIPS eligible clinicians. Since you are not eligible, the payment adjustments will not apply to you.
Rick, have you seen the final rule regarding FLR or have an estimate release date for the final rule? In this rule, it only says CMS is finalizing their final rule. As an institutional biller, we cannot discontinue the FLR’s until we have that final ruling in hand from CMS. Thanks for the help.
Finalizing means they finalized what they proposed. FLR ends for traditional Medicare at the end of this year.
With Functional Limitation Reporting no longer required for 2019, is there any requirements or guidelines on having to complete discharge FLR on the final date of service for 2018 or are we able to just stop completing the reporting moving forward as of 1/1/2019? Thanks as always for you assistance and guidance.
The last date to report FLR for traditional Medicare is December 31,2018.
Rick, I know you have received many questions. I will make this brief. When G codes FLR was in place and patient wanted to stop treating for one body part and start treating for another, we had to discharge with the proper dc g codes and then eval the new issue. Now that g codes are going away, do we still need to have patient officially dc before evaluating the new issue? Thank you. Lori F
For 2018, you follow the FLR as they have always been. In 2019, FLR is no longer required for traditional Medicare.