Medicare Changes

Patient Driven Payment Model (PDPM)

On July 2018, CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay.  
Please review the link below for updated information with updated FAQs and ICD 10 mappings.   



Update 11/6/18
Part 1 and 2 is below



The first two articles presented the fundamentals of the Merit-based Incentive Payment System (MIPS). Part 1 included background information on MIPS, participation requirements and low threshold determinations along with reporting methods and requirements. Part 2 discussed the Quality Measures to be collected along with the Improvement Activities that need to be carried out and reported. Collection and reporting mechanisms were also discussed.

Part 3 will cover the requirements for data completeness reporting, the scoring process and determination of bonus penalty methods. As always, what matters most is how this data will be used by CMS to determine your payment levels.

Data Completeness

CMS requires that you report your quality measures on at least 60% of the eligible patients at the time of the initial evaluation (CPT codes 97161, 97162 and 97163). Unfortunately, your reporting method will determine which patients you must report on to meet the 60% threshold. If you report by claims (part 2) it must be on at least 60% of all Medicare Part B Fee for Service patients only. This does not include patients insured by a Medicare Advantage Plan. If you report via a Qualified Clinical Data Registry (QCDR) or another registry (part 2) you must report on 60% or all eligible patients for all payers. Furthermore, the word eligible is critical because it defines your reporting population.

For example, for measure #131 Pain Assessment and Follow-up the description states:

“Percentage of visits for patients 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present” 1.

For this pain measure you must report on at least 60% of all your patients over the age of 18 regardless of their insurer. This holds true for all of the Quality Measures except #101 Falls Risk Assessment and Plan of Care. This measure is only applicable to patients 65 years and older.

Included in the concept of data completeness you are required to report on 6 Quality Measures, if possible. For those reporting via claims, you only have 5 measures for 2019. That means to meet the data completeness requirement you must report all 5 measures on at least 60% of your eligible patients. Furthermore, and this is really important, one of those measures must be a functional outcome measure. For those of you accustomed to collecting an outcome measurement score at the outset of care this will be easy to satisfy; business as usual. For those of you who have not been collecting an outcome measure on your initial evaluation visit this may be a new challenge to include this in your intake process.

If you are reporting through a QCDR or another registry you must report on 6 measures. These can include the Focus on Therapeutic Outcomes (FOTO) measures. If you don’t use FOTO, then it appears there will be some additional QCDR specific measures you will be able to use, although it is not clear exactly what those are at this time. Stay tuned for more information.

Data completeness for Improvement Activities consists of meeting the minimum required score for activities for that reporting year. Part 2 described some of the Improvement Activities and how they were scored. You will need to achieve 40 points for the year. This could be made up of 2 high weighted activities (20 points each), 1 high weighted and 2 medium weighted activities (10 points each) or 4 medium weighted activities. As long as you submit enough for 40 points you will have achieved data completeness for Improvement Activities. Remember, small practices (less than 15 eligible providers) get a break on this. They get double points for activities so a high weighted activity is worth 40 points and a medium weighted activity is worth 20 points.


In addition to the 40 points for Improvement Activities, you will be scored on each Quality Measure (also described in part 2). CMS will compare your reporting percentages to a national benchmark and assign a score from 3-10. CMS has not determined the benchmarks yet and apparently, they can vary by reporting mechanism. These scores are added to your Improvement Activities to give you an overall score for the individual or group. If you are reporting as a group it appears they will be averaging your reporting percentages for all providers, regardless of whether they meet the low threshold limit, and giving a group score for that percentage. The following Table provides more detail on how the activities will be scored 2. You can also earn bonus points if you meet the Class 1 requirements for any of 4 high priority Quality Measures. Those high priority measures are listed here.





Scoring rules


Class 1

The measure can be scored based on performance.

The measure meets all of the following criteria:
(1) Has a benchmark;
(2) Has at least 20 cases; and
(3) Meets the 60% data completeness standard.

Class 1 measures will be awarded 3 to 10 points based on performance compared with the benchmark.

Class 2

The measure meets the 60% data completeness standard but does not have both a benchmark and at least 20 cases.

Class 2 measures will be awarded 3 points.

Class 3

The measure has a benchmark and was submitted but it does not meet the 60% data completeness standard.

Class 3 measures will be awarded 1 point, except for small practices, which will receive 3 points.


As an example of the scoring:

You’ve reported on 2 high-weighted Improvement Activities like “Promote the Use of Patient Reported Outcome Tools” and “Collection and follow-up on patient experience and satisfaction data on beneficiary engagement”, so you get 40 points. Then you report on 6 Quality measures that meet the Class 1 criteria. Let’s say you do well and your 6 measures are scored at 8, 7, 7, 7, 6, 9, for a total of 44. Your total score then is 84. This score will be used to determine your bonus or penalty for the payment year.

Bonus or Penalty Determination

Once your total score, along with all other practices/individuals scores, are determined for the year the bonus/penalty will be determined. The minimum threshold score for any bonus for 2019 is 30 points total. Thirty points will be payment neutral, meaning you will not be penalized nor will you receive a bonus. If you earn less than 30 points you will be penalized some percentage. If you earn more than 30 points there will be some bonus. If you score more than 80 points you will be eligible for an additional bonus payment. Clearly, the higher the score the better the bonus. The bonus/penalty range is -7 to +7% on payments.

There is a major caveat, however. The bonus/penalty levels are designed to be budget neutral. Which means for every provider/group that receives a +4% increase there will need to be a provider/group with a -4% penalty. The bonus/penalty levels will not be determined until after all the data is in and all providers have been scored. CMS will then decide bonus/penalty levels.

To gain some perspective on the bonus/penalty award it appears that in the first year of MIPS, when the bonus/penalty limits were -4 to +4%, the highest bonus payout levels were 2%. Thus it appears that the ultimate range of the true bonus/penalty will be fairly narrow.

As noted in the past this information is still based on the proposed rule. The final rule is due out later this week on or around November 1st. APTA will certainly analyze the final rule and develop more guiding information for everyone. The APTA page on Value Based Care will be updated and the place to go for the latest information.

One Last Comment

This first foray into payment for value is just about participation with your scores based solely on your percentage of reporting. There is no assessment of the quality or success of the care provided…yet. CMS has given every indication to APTA staff that they are going there. At some point, not too far down the road, it will be about scoring your effectiveness in the care of your patients which will influence your payments.

Prudent providers should begin to look at their effectiveness in achieving their patient’s desired outcomes. Using registry data is the best way to accomplish this. If your EMR vendor includes a registry then make sure you are assessing the data provided and using it to improve yourself and/or your staff effectiveness. If you don’t have a registry with your documentation system then it would be strongly advisable to consider the Physical Therapy Outcome Registry at APTA. It will provide everything you need to help you move to more value based care. The benefits you can get from using this data far outweigh the costs. Besides, it’s becoming clear you can’t afford not to move in this direction now.

  1. APTA accessed at Oct 2018. 
  1. Participating in MIPS: What You Need to Know accessed at Oct 2018.


MIPS. IS. HERE. Part 2


This is the second article in the series on the Merit-based Incentive Payment System (MIPS). The first part presented background information on MIPS, participation requirements and low threshold determinations along with reporting methods and requirements.

In this Part 2, the two performance categories physical therapists must report, the measures PT’s will need to report, and how they are gathered are presented. As an FYI, APTA’s Regulatory Affairs division has recently published very detailed information on the website regarding the Quality Payment Program, MIPS and the Advanced Alternative Payment System (AAPM).

As a refresher, those participating in MIPS reporting in 2019 have 4 categories that are being scored to determine the level of payment bonus or penalty. These categories are Quality, Improvement Activities, Cost, and Promoting Interoperability. For 2019, physical therapists are only being asked to report on two; Quality and Improvement Activities. The scores for these two categories will be weighted (more on that in Part 3) and the payments will occur in 2021.

Quality Measures

Let’s consider the Quality measures first. CMS developed a PT/OT Measures Set that is designated for PT/OT use.  We are required to report on a minimum of 6 measures or as many as are applicable/available. The applicable/available requirement means you should try for 6 if you can; however, for PT’s reporting via claims (see below) there are only 5 measures currently available. So you would report on these five only. At some point in the future it is highly possible that more measures will be added to the PT/OT Measures Set.

The following are the 5 Quality measures that can be reported through claims:

  • Falls: Screening, Risk-Assessment and Plan of Care to Prevent Future Falls.
  • Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan
  • Documentation of Current Medication in the Medical Record
  • Pain Assessment and Follow-up
  • Functional Outcome Assessment.

Most of these should look familiar to you if you reported PQRS measures in the past. The one change is the combining of the Falls Risk Assessment measure with the Falls Risk Plan measure to create only one. Claims based reporting will occur on the HCFA 1500 form, similar to reporting PQRS.

If you are able to report through a Data Registry there are 7 more that are also available to you:

  • Functional Status Change for Patients with Knee Impairments.
  • Functional Status Change for Patients with Hip Impairments.
  • Functional Status Change for Patients with Foot or Ankle Impairments.
  • Functional Status Change for Patients with Lumbar Impairments.
  • Functional Status Change for Patients with Shoulder Impairments.
  • Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
  • Functional Status Change for Patients with Other General Orthopedic Impairments.

Many of you may recognize these as measures from Focus on Therapeutic Outcomes Inc. (FOTO). Reporting through claims is only available to small practices (defined as having less than 15 eligible providers). Small practices may choose to report through a registry if they participate, but that is not a requirement at this time. Groups with more than 15 eligible providers must report through one of the Qualified Clinical Data Registry’s.

So if you are a small practice, you report through your claims and only have to report on the first five measures. If you participate in a registry you may report on one additional measure (6) through the registry. If you are a large practice you must report 6 measures through a registry. You do not have to report more because only those 6 will be scored and you do not get any more points towards your total score for reporting more. If you do report more than 6 only the six highest scored measures will be counted. I suggest you set up your systems to only obtain 5-6 measures depending on your practice size.

Improvement Activities

The second category involves Improvement Activities. CMS considers these as activities that improve clinical practice1. These activities have to be performed for 90 consecutive days through the course of the reporting year. They are designated as high weighted (worth 20 points) or medium weighted (worth 10 points) for purposes of valuing. CMS has not determined the values of the activities for us yet but when the final rule is posted they will be placed in a value category. The requirement is to report activities that total 40 points which could be any combination of high and medium weighted activities.

There are a large number of Improvement Activities that are available but most are not appropriate for physical therapists. APTA is reviewing the list of activities and will be posting the most appropriate ones available. Some examples from a recent webinar include:

  • Promoting Use of Patient Reported Outcome Measures.
  • Use of a Qualified Clinical Data Registry (like APTA’s Physical Therapy Outcomes Registry).
  • Improved Practices that Disseminate Appropriate Self-Management Materials in Appropriate Language.

Unlike the Quality measures Improvement Activities will be reported directly to CMS by attestation. You will log-in to a specific website with a unique password one time in the reporting period, which is any 90 day period in that reporting year, and attest to which activities you completed. You will also be able to log-on to the CMS website and directly report via a specific form, although this form is not yet accessible. It is highly recommended you keep very good documentation of the Improvement Activities in case you are ever audited by CMS.

One caveat on the scoring of Improvement activities; for small practices the weights will be doubled, meaning a high weight activity will be worth 40 points and a medium weight activity will be worth 20 points. This will make it easier for small practices to comply with the requirement.

It is very important to note these measures are to be reported only once during the episode of care at the initial evaluation, e.g. with CPT codes 97161, 97162, 97163. You are not required to report them any other time since they are tied to these three Physical Therapy Evaluation CPT codes.

What should you do now to prepare?

  • Continue to learn as much as you can about MIPS (the APTA website is updating regularly).
  • Insure in your evaluation process that your system prompts your staff to collect the Quality Measures.
  • Contact your billing/EMR company regarding their readiness to report for you.
  • If you are a large practice explore registry’s to decide which will serve you best.
  • Educate staff on the Quality and Improvement Activities.
  • Begin to determine if you have at least 2 high value, 1 high value and 2 medium value or 4 medium value Improvement Activities in place. If not, begin to institute them.

In Part 3 we will review the requirements for data completeness, the scoring process and requirements as well as how the payment bonus/penalty will be determine. As a reminder all this is still a proposed rule. Most of it is likely to be finalized but changes could still occur. After all it is the federal government and it is CMS.


  1. CMS Quality Payment Program: MIPS. Accessed at August 2018.





submitted 8 / 2018

MIPS. IS. HERE. Part 1
The long awaited and well forewarned Merit-based Incentive Payment System (MIPS) is finally here for physical therapists. APTA has been talking about this for some time now. Previously physical therapists have not been eligible as participants but that all changes next year.
A series of articles will be presented to augment the preponderance of information APTA will be posting. The focus of this series will attempt to explain MIPS in greater detail and to describe exactly what you need to do to make this work for you. The first article will present an overview and discuss participation.
To give you some background, MIPS was required by Congress in the Medicare Access and CHIPS Re-authorization Act of 2105 (MACRA). This is the same legislation that repealed the Sustainable Growth Rate that we fought for so long (success!). MACRA established the Quality Payment Program (QPP) changing the way Medicare pays providers. It moves to rewarding value-based care instead of volume of care. MIPS and the Advanced Alternative Payment System (AAPS) were created as part of QPP. Only MIPS will be addressed here for now as AAPS is more complicated and less relevant.
Beginning January 1, 2019 private practice physical therapists with NPI numbers and billing Medicare Part B are considered MIPS eligible clinicians. Occupational therapists, clinical psychologists, and clinical social workers are also considered eligible in 2019. Notice this list does not include Speech and Language Pathologists, PTA’s or COTA’s. Hospital outpatient rehabilitation services are also not included now, but keep posted on that for the future.
There is a low threshold determination that further sets the bar on participation. If you have less than $90,000 in Medicare allowable billed charges, or fewer than 200 Medicare patients, or provide less than 200 Medicare covered services per year (read total number of units of CPT codes billed to Medicare) you are not required to participate. Medicare will help you figure this out.

Here is where it gets a little tricky. The low threshold requirement can be applied as an individual, group or virtual group. You may opt to participate as an individual or as a group. However, those are specifically defined. An individual is a provider with an NPI number and their own Tax Identification Number (TIN) where they assign payment. This most likely will be a solo practitioner. A group is defined as 2 or more eligible individuals with NPI numbers who have reassigned their payment benefits to the group TIN. This includes most people who work for a practice owned by someone else. A virtual group is comprised of up to 10 solo practitioners from anywhere who band together to participate in MIPS for one year. Remember this is only for private practice physical therapists for now. A MIPS score is calculate for the individual or the entire group or virtual group, depending on how you choose to report. It is also possible to “opt-in” to MIPS even if you don’t meet the low volume threshold. APTA recommends this as preparation for the time when the threshold is met.
MIPS allows payment to be adjusted based on performance. The amount of adjustment for physical therapists will range from -7% to +7%. More on how payment is determined will be covered in Part 2 of this series. The data required by CMS for MIPS can be reported through a certified EHR or a Qualified Clinical Data Registry. If you use an EHR or participate in a registry make sure it qualifies to be able to submit to CMS. All groups of 15 or more are required to report their data via EHR or registry. The Physical Therapy Outcomes Registry is certified by CMS making it one avenue to report. Groups of less than 15 may report through their claims. However, that is not likely to last forever so it’s important to begin to plan to either participate with a registry or choose an EHR, or both.
MIPS involves scoring in four categories, Quality, Cost, Improvement Activities,and Promoting Interoperability. For now, PT’s and OT’s will only be scored on Quality and Improvement Activities. More information on the measures to report and scoring process to come in Part 2.
Finally it is important to understand the difference between the participation year and the payment year. Eligible physical therapists are required to participate starting in 2019. January 1, 2019 to December 31, 2019 is considered the participation year. A new data collection year will start January 1, 2020. Medicare will tally and assess the scores for 2019 and make a determination on the level of payment adjustment for your practice. That adjustment will then be applied to payments over the course of the payment year 2021. That process repeats itself for each year thereafter with payment year adjustment based on the performance scores for the participation year. Scores generated based on data provided in 2020 will be determine the adjustments for payment year 2022.
What should you do right now?
  •       Start by reading all the information provided by APTA and CMS.
  •       Attend or listen to all recorded Webinars as are available. Learn everything possible about this process.
  •       Begin to educate your staff. It is complicated so it will take time to train your staff.
  •       If you already use an EHR determine if it is Medicare certified.
  •       Explore participation in an outcome registry, if you already participate be sure it is a qualified registry.
  •       If you are not already collecting outcomes data at the initial evaluation and discharge then you must make this a mandatory part of your process.
In Part 2, the Quality and Improvement Activities that PT’s will be assessed on will be discussed. Exactly which measurements required to be reported in those categories and the scoring process will also be discussed. Suggestions on ways to comply will also be provided. 
Stay tuned for an upcoming meeting with the Private Practice SIG in September to address this more.
Submitted by CTAPTA Federal Affairs Liaison, Victor Vaughan
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