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Payment & Practice Resources
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HPA offers a number of resources to its members related to health policy and reimbursement.

 

Take Action!:

Provide Comments to CMS re: Proposed Application of CQ and CO Modifiers.

Under the Bipartisan Budget Act of 2018 Section 53107, beginning Jan. 1, 2020, outpatient therapy providers are required to use a modifier to denote when outpatient therapy services are furnished in whole or in part by a PTA or OTA. In 2022, payment for outpatient therapy services furnished in whole or in part by a PTA or OTA will be reimbursed at 85% of the fee schedule. The reduced payment rate is applicable when payment is made under the PFS to therapists in private practice, outpatient hospitals, rehab agencies, SNFs, HHAs, and CORFs). In the 2019 PFS final rule, CMS clarified that the CQ and CO modifiers are required to be used when applicable for services furnished on or after Jan. 1, 2020, on the claim line of the service alongside the respective GP or GO therapy modifier to identify services furnished under a physical therapy or occupational therapy plan of care. CMS also finalized a de minimis standard under which a service is considered to be furnished in whole or in part by a PTA or OTA when more than 10% of the service is furnished by the PTA or OTA. CMS also noted they would be putting forth more guidance in the 2020 PFS rule.


FAQs:

*New* Patient-Driven Model (PDPM) FAQs

The Patient-Driven Payment Model (PDPM) for skilled nursing facilities will be in effect beginning October 1, 2019. Here are some frequently asked questions about the revised case-mix methodology. These FAQs were developed during the proposed final rule for Skilled Nursing Facilities.  The Final rule was published on 7/30/19.  APTA will be releasing a summary of the final rule and we suggest accessing this once available.  

 

These FAQs were developed by The Post -Acute Care Reimbursement Model Change Collaborative which includes members from: HPA The Catalyst, Academy of Geriatric PT, and the Home Health Section, and regulatory staff of APTA (in particular Kara Gainer, JD, Director of Regulatory Affairs, and Alice Bell, PT, DPT, Board Certified Clinical Specialist in Geriatric Physical Therapy, Sr. Payment Specialist).


HPA Forum:

The HPA Forum is an outstanding resource available to members to keep abreast of policy and reimbursement changes.


Medicare & CMS:

Centers for Medicare & Medicaid Services (CMS) General Information

Therapy Cap

Functional Limitation Reporting (APTA)

Coding

Fraud & Abuse

Medicare Physician Fee Schedule

Medicare Physician Fee Schedule -The Centers for Medicare and Medicaid Services (CMS) reimburses for outpatient therapy services under Medicare Part B utilizing the Medicare Physician Fee Schedule (MPFS) in all settings accept for critical access hospitals (CAH's). CAH's are reimbursed on a cost basis. CMS has developed a fee schedule that encompasses work expenses, practice expenses, and malpractice expenses for each modality and procedure (CPT code) that therapists provide to their Medicare patients. The amount that CMS reimburses is dependent upon the area in the country that you provide the outpatient therapy services. Currently, there are 91 localities in the encompassing the United States, Puerto Rico, and Guam.

Please follow the link below to obtain the reimbursement information you are seeking. Click "start" on the first page. Choose if you want pricing information on a single CPT code, list of CPT codes, or range of CPT codes then click "next." Under "Select Carrier Option" choose "Specific Locality." And then click "next." Complete the CPT code(s) or range of CPT codes you want pricing information on. For the drop down box for "modifiers," select "all modifiers." For locality, choose your specific locality where you do business. Keep in mind that all settings are reimbursed the non-facility rate for outpatient therapy services.

Medicare Physician Fee Schedule


Payment Toolbox:

The toolbox features file libraries of information and resources related to physical therapy payment and practice. Each library also includes a Wiki feature that allows members to share additional resources through the library. HPA members must be logged into the website to access the toolbox.


APTA's Resources:

 APTA's payment page with links to various insurer information.

 

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