CMS Releases 2018 Final Rule for Services Paid Under the MPFS

November 3, 2017
Rick Gawenda

On November 2, 2017, the Centers for Medicare and Medicaid Services (CMS) released the final rule for services paid under the Medicare Physician Fee Schedule (MPFS). This final rule impacts providers and suppliers of outpatient physical and occupational therapy services as well as speech-language pathology services. This would include outpatient therapy services provided in the following settings:

  • Private Practice
  • Skilled Nursing Facility Part B Therapy
  • Comprehensive Outpatient Rehabilitation Facility
  • Rehabilitation Agency
  • Home Health Doing Part B in the Home
  • Hospital Outpatient Departments

Highlights of the final rule include:

  • 2018 annual therapy cap dollar threshold and manual medical review process
  • New and revised CPT codes for orthotic and prosthetic management and training
  • New CPT code for cognitive function intervention that CMS will not pay for
  • New HCPCS Level II code for cognitive skills that CMS will pay for
  • 2018 conversion factor used to determine payment for each CPT code
  • Changes to work RVU’s and practice expense RVU’s for therapy CPT codes

Therapy Cap

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  1. Rick, I read the information related to Telehealth. It restated the information you posted on July 14th. Interestingly, the document notes an “original requestor” of the services being added to the Medicare telehealth list. Is there a way to find out what organization or individual submitted? I’m curious about the data to support their request.

    Thanks, Will
    PS safe travels

  2. Rick, are they proceeding with the proposed changes to the Multi-layer compression system codes that were in your Sept 25, 2017 post?
    Mary McLaughlin

  3. Rick, great information. Thanks you.
    Any insight into how the 2018 COP updates to HHC will impact HHC agencies providing outpatient therapy? Any resources you can direct us to?

    1. I would tell you to contact the Home Health Section of the American Physical Therapy Association.

  4. In the final rule, CMS finalized their proposal to create HCPCS code G0515 to mirror the coding and valuation of existing CPT code 97532, instead of adopting CPT code 97127
    Rick what exactly does this mean when we bill Medicare? Is it still timed or untimed? Is the RVU staying at 0.44or increasing to 1.50
    Billing systems will need to be built to accommodate both 97127 and G0515?

    1. CMS will keep the same description that currently exists in CPT code 97532 for G0515 and will maintain the current relative value units that currently exist for 97532. This means G0515 will remain a time-based CPT code.

  5. Rick
    Will you clarify if Critical Access Hospitals (CAH) & Hospital-based therapy depts. are exempt form the CAP? We are aware if a pt. transfers from a CAH or hospital-based dept, the therapy used in that spot will count against the CAP if they transfer to an ambulatory setting / traditional OP setting. Do we need to keep track of the $ threshold while the recipient is receiving therapy in a CAH or hospital-based dept? T

      1. Information on the APTA website indicates the hospital outpatient therapy depts. are now excluded from the cap. Can you verify that?

  6. Rick,
    I’m not a Gold Member, but I was hoping you could at least address whether there has been any indication from CMS that they are ready to consider a tiered payment structure for the three eval codes. In reviewing CMS info, I saw no such indication. Also, do you have a link to a 2018 searchable CMS Fee Schedule? All I see is the 2017 schedule.

    Jeremy Ramage, PT,MPT,NCS

  7. Regarding code 97760, would we also charge 97161,2,or3 for measurements taken for treatment purposes? The CMS definition of the code is “Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(ies), lower extremity(ies) and/or trunk, initial orthotic(s) encounter, each 15 minutes)”. My initial thought is that is assessment of the orthotic, not patient. Thanks!

  8. Hi Rick, I have a few questions about the 2018 CPT changes:
    1. Do you know if other payers will recognize the G0515 code replacing 97532? Short of contact every payer individually, is there an easier way to find out?

    2. When using the 97760 and 97761, will this be used in lieu of an evaluation charge since it is for an initial visit only or can we bill it in conjunction with the eval like we do a treatment charge? It sounds like we use it instead of – ?

    1. 1. You will have to check with each insurance carrier.
      2. There is not one answer to give regarding 97760 and 97761. I have several article on my website concerning 97760 and L codes.

  9. Rick, we have much discussion about the use of L-code and 97760. If a patient presents for a splint/orthotic, would it be appropriate to bill the L-code on the first visit, and then on the second visit if adjustments or assessment of the splint is made we would bill 97760. If there was a 3rd visit where we assessed or modified we would bill 97763?

    1. If billing the L code for the orthosis, any adjustments that you within 90 days are included in the L code payment.

  10. Rick do you have any training/articles available on RVUs. We are providers in Iowa and having difficulty finding the Iowa medicaid rvu work, practice expense and malpractice values.

    thank you

    1. You would have to check with Iowa Medicaid to see if they determine CPT code payment based on RVUs. If yes, you then need to check with your Medicaid program to locate the RVUs.