CMS Releases Proposed Rule for 2019 for Therapy Services

July 12, 2018
Rick Gawenda

On July 12, 2018, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule: “Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; and Medicaid Promoting Interoperability Program”. This proposed rule has several proposed changes for outpatient therapy services beginning with dates of service on and after January 1, 2019.

Highlights of the proposed rule include the following:

  • Functional limitation reporting
  • Revised description for GN, GO and GP discipline specific modifiers
  • New modifiers for services provided by a physical therapist assistant (PTA) or occupational therapy assistant (OTA)
  • Merit-Based Incentive Payment System (MIPS)
  • Revise direct practice expense inputs for 3 CPT codes utilized by physical and occupational therapy

Lets begin!

1. Functional Limitation Reporting

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    1. Yes! It was burdensome and provided useless data to CMS. In addition, CMS found they were not useful in considering how to reform payment for therapy services as an alternative to the therapy caps.

      1. Is there any way to discover the amount of money Medicare spent (wasted) in implementing and managing FLR?

  1. Where can I find more information about MIPS? Will have any webinars on MIPS?
    Thank you

  2. Do you know if anyone, APTA etc.., is fighting the PTA & OTA reimbursement cuts? Or does it seem to be a done deal?

  3. Can you post a link to Appendix B that you mentioned above? I can’t find it on Medicare’s terrible website.

  4. Do you know if the MIPS rules will apply only to private practice and not SNF, IRF, and other UB04 billers (similar to PQRS)?

  5. Is EF028 really billed in outpatient private practice? I have never heard of this code or know how to use it.

  6. To a small out patient OT and PT private practice, that is not using EMR at this time, how will this new MIPS system effect us ?

    1. We will not know the complete roll out of MIPS until the final rule is released on or around November 1, 2018.

  7. I am concerned that the modifier is the same whether the visit is provided “in whole or “in part” by a PTA. Those are VERY different scenarios! Has APTA considered pushing back on that?


    1. My opinion is that APTA will provide suggestions on what “in part” means and looks likes.

  8. With PDPM they are saying PT and OT will cap at 25% of total therapy time yet we were not going to have to track the minuets so will the 25%caps be enforced with the entire therapy stay?

  9. This is all very interesting. Just curious if you know how payment is affected for Physcian Assitance.

  10. CMS recently published their proposed rule for 2019. If the proposal goes into effect, therapist will join the list of providers who must participate in the CMS Quality Payment Program. Since we are hospital-based OP rehab departments and ambulatory clinics, will this apply to us. We file to Medicare Part A using a group PTAN and group NPI #.

    1. The final rule is due out on or around November 1, 2018. Watch for an updated article on my website.

  11. With FLR ending Jan 1st, will clinics need to continue reporting to complete claims rolling over into 2019. Or can they just stop all reproting as of Jan 1st?