Current Updates

August 2022

CIGNA

Dear APTA  members, As you are probably aware, Cigna has recently made notice of their intent to impose a 4 unit per visit limitation and a 15% payment differential for services provided by a PTA effective October 15th with TX,  KY, CO, and OH starting on November 1st.  New Cigna policies are shown below and described here: 873827_ExternalHCP_Template2014_V2 (mercyoptions.net) and CHCP - Resources - Policy Updates July 2022 (cigna.com)
PTA differential: Modifiers CO and CQ reimbursement reduction for physical or occupational therapy assistant services Reimbursement for claims submitted with modifiers CO and CQ for services provided by a physical therapy (PT) or occupational therapy (OT) assistant will be reduced by 15 percent. This update more closely aligns with industry standards, including the CMS National Physician Fee Schedule, which reimburses these services at 85 percent. We will update the Health Care Common Procedure Coding System (HCPCS) National Level II Modifiers reimbursement policy to reflect this change. This update is effective for dates of service on or after October 15, 2022 (in all states except TX, KY, CO, and OH where it starts on November 1st). 4 unit per visit limit:  Physical therapy, occupational therapy, and chiropractic claims for greater than four units (60 minutes) of timed service. The portion of a physical therapy (PT), occupational therapy (OT), or chiropractic claim that is greater than four units (60 minutes) of timed, short-term rehabilitation services per patient, per day, per provider will be denied as being not medically necessary. We will update the Omnibus Codes (0504) medical coverage policy to reflect this change. This update is effective for dates of service on or after October 15, 2022 (except in TX, KY, CO, and OH where it starts on November 1st). APTA has been in contact with Cigna and is gathering details on the rollout. Here is what we know thus far:
a.       Cigna direct agreements including outpatient hospital facilities are impacted.
b.       Cigna out of network providers will be impacted by the policy changes.
c.       There are no plan exclusions.
d.       There will be negligible impact for providers contracted with ASH (American Specialty Health). ASH will not implement the PTA/OTA modifiers and the four unit per visit limitation of timed codes is already built into the ASH utilization review process.
e.       There is an exception process in place based on medical necessity review with appeal rights for the 4 unit per visit limitation.
f.        ASH notified providers on 8/1/22.
g.       Cigna notified providers around 8/3/22. 

APTA PTA differential and CQ modifier resources are found here: https://www.apta.org/search?Q=PTA+differential&sort=0 and https://www.apta.org/apta-magazine/2020/03/01/compliance-matters-how-to-apply-the-new-cq-modifier 
  1. Evernorth article highlighting value of PT  (Evernorth is under the Cigna umbrella. Used to be Cigna behavioral health.)
Evernorth: How payers can mitigate high MSK care costs (fiercehealthcare.com) Verifies early PT for MSK particularly LBP reduces HC costs, improves outcomes, and eliminates more invasive/ costly procedures. Closely mirrors the Optum findings. Another advocacy tool.   
  1. NIA/ Magellan
  • In person meeting is scheduled for 9/29/22. Please forward agenda items.
  • Just released NIA Guidelines

National Imaging Associates: Outpatient Habilitative PT and OT Therapy - Guideline

View Full Policy - PDF

View Full Policy - Payer Website

Anthem: Provider News Colorado, Connecticut, Georgia, Maine, Missouri, New Hampshire, and Ohio - News & Announcements


Payer has announced various new policies, criteria, guideline, and coding changes. Please refer to the attached bulletin for complete information.

The policy-related alerts in this New Hampshire bulletin also apply to the states of Colorado, Connecticut, Georgia, Maine, Missouri, and Ohio. Use the following links to view the other state-specific bulletins:
Colorado - https://anthempc-attachments-prod.s3.us-west-2.amazonaws.com/pdf/publications/August%20%202022%20Anthem%20Provider%20N...%20-%20pub1448.pdf
Connecticut - https://anthempc-attachments-prod.s3.us-west-2.amazonaws.com/pdf/publications/August%202022%20Anthem%20Connecticut...%20-%20pub1450.pdf
Georgia - https://anthempc-attachments-prod.s3.us-west-2.amazonaws.com/pdf/publications/August%202022%20Anthem%20Provider%20Ne...%20-%20pub1446.pdf
Maine - https://anthempc-attachments-prod.s3.us-west-2.amazonaws.com/pdf/publications/August%202022%20Anthem%20Maine%20Provi...%20-%20pub1451.pdf
Missouri - https://anthempc-attachments-prod.s3.us-west-2.amazonaws.com/pdf/publications/August%202022%20Anthem%20Provider%20Ne...%20-%20pub1455.pdf
Ohio - https://anthempc-attachments-prod.s3.us-west-2.amazonaws.com/pdf/publications/August%202022%20Anthem%20Provider%20Ne...%20-%20pub1456.pdf


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View Full Policy - Payer Website

  1. Articles
Curana Health's innovative 3-in-1 value-based care model for seniors: 12 things to know (beckerspayer.com)Humana's 18.5% net income boost in Q2: 8 notes (beckerspayer.com)Optum vs. Amazon after the $3.9B One Medical deal (beckershospitalreview.com)13 recent payer moves to exit or enter markets (beckerspayer.com)11 payers entering, exiting markets (beckerspayer.com)Payer economic trends and insights, per Moody's: 5 notes (beckerspayer.com)

 

March 2022

Medicare Fee Schedule

APTA and our Fee Schedule Coalition partners continue to push Congress for large-scale reforms to the Medicare Fee Schedule and MIPS. In a letter to the chairs and ranking members of the Finance, Ways and Means, and Energy and Commerce committees in the U.S. Senate and House of Representatives, APTA along with 95 organizations called on Congress to "immediately initiate formal proceedings (hearings, roundtables, expert panels, etc.) to discuss potential reforms to the Medicare physician payment system to ensure continued beneficiary access to care. Additional details HERE 

PAYMENT AND PRACTICE UPDATES 

APTA and Patient, Provider Groups Continue PTA Differential Push

In a joint letter to congressional leaders, APTA and 11 other groups urge adoption of legislation to address the PTA payment cut.

News

Date: Wednesday, February 9, 2022

A dozen organizations including APTA have joined together to press Congress to take action on the 15% payment cuts rolled out this year for services delivered by PTAs and occupational therapy assistants under Medicare. In a letter to congressional leaders, the groups write that "there could not be a worse time than now" to carry out the payment differential, and they urge support for a bill that would mitigate some of the most damaging parts of the differential system.

The letter, signed by groups including the American Occupational Therapy Association, the Brain Injury Association of America, United Cerebral Palsy, and the National Association for Rehabilitation Providers and Agencies, calls for lawmakers to include the Stabilizing Medicare Access to Rehabilitation and Therapy Act, or SMART Act (H.R. 5536), as part of any upcoming must-pass continuing resolution or omnibus package to keep the federal government operating.

The SMART Act, sponsored by Rep. Bobby Rush, D-Ill., and Jason Smith, R-Mo., continues to be the focus of APTA grassroots efforts, with the association calling on members and supporters to contact legislators to support the bipartisan bill. (Visit the APTA Patient Action Center to send a message to your legislators, and sign up for the APTA Advocacy Network, a free service that sends you special legislative updates and action alerts.)

As of the publication date of this article, the U.S. House of Representatives passed a continuing resolution without the SMART Act included, but it only funds the government through March 11. That means even if the House-approved resolution passes in the Senate, a new one will need to be hammered out in the coming weeks. Additionally, lawmakers could pass omnibus legislation that would address multiple issues. Either action could include the SMART Act provisions.
The SMART Act doesn’t completely eliminate the differential system, which the U.S. Centers for Medicare & Medicaid Services argues is required by law, but it does delay implementation for a year and blunt some of its effects. Among provisions of the SMART Act supported by APTA, in addition to the one year delay: establishment of an exemption to the differential for rural and underserved areas, and adoption of less burdensome general PTA and OTA supervision requirements for outpatient therapy under Medicare Part B .

"Given staffing shortages and recruitment difficulties facing rehabilitation therapy providers as a result of the pandemic, there could not be a worse time than now to cut payments for services provided by occupational therapy assistants and physical therapist assistants," the letter states. "These professionals are a crucial part of the therapy workforce and ensuring that beneficiaries have access to therapy services."

 

 

Planned Medicare Telehealth Code Changes Send Ripples Through Private Payers

Do you provide services via telehealth? Get up to speed on anticipated changes to the codes you’ll use.

News

Date: Monday, January 31, 2022

PTs and PTAs who provide services via telehealth, be aware: The U.S. Centers for Medicare & Medicaid Services has introduced changes to coding that could affect you in April, if not sooner.

The changes have to do with place-of-service, or POS, codes. Specifically, the agency updated its description of POS 2, “telehealth provided other than in patient's home,” and created a new code, POS 10, “telehealth provided in patient's home” to better reflect the realities of telehealth and prepare for the end of the public health emergency, which currently extends through April 16.

Currently, telehealth services rendered by PTs and PTAs, like most telehealth services, are associated with the same POS code as would be used had the service been provided in person (for instance, the outpatient clinic that the patient would’ve visited). The POS 2 and 10 changes announced by CMS became effective on Jan. 1, but Medicare administrative contractors have been told to hold off on processing claims with these codes until April 4. So for now, PTs and PTAs providing telehealth to Medicare beneficiaries can continue coding as they've been doing but should prepare for a change. Current guidance can be found in Chapter 12, Section 190 of the Medicare Claims Processing Manual.

The same timeline may not hold true for commercial payers. In fact, some commercial payers are already advising providers to start using the POS 2 and 10 codes — and at least one payer has indicated that it will decrease payment when either POS 2 or 10 is used.

The changes to the POS codes don’t answer the bigger question of what will happen to the ability of PTs and PTAs to provide services via telehealth after the public health emergency ends. While a few private insurers, including UnitedHealthCare, have committed to extending this ability beyond the PHE, many more have remained silent on what they'll do. APTA is engaging with commercial insurers to make the case for the adoption of permanent telehealth provisions.

At the federal level, CMS maintains that it’s restricted by law from making any permanent changes to its list of providers who can provide services via telehealth. APTA and other organizations are advocating for legislation that would permanently open telehealth to PTs and PTAs under Medicare, and allow for more flexibility in the U.S. Department of Health and Human Services’ ability to make changes.

Questions on the POS code changes? Contact advocacy@apta.org

 

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