The Proposed Rule 2021: An Overview for PTs, Occupational Therapists and Speech-Language Pathologists

Each year, around the end of July, the Centers for Medicare and Medicaid Services (CMS) releases a document with all of the proposed policy changes they want to implement in the coming year. And this year, the proposed rule is a roller coaster for rehabilitation therapists. CMS has proposed legislative changes which are clear victories for PTs, TOs and SLPs, as well as certain changes and reductions in payment which could be seriously detrimental to the entire industry. So, buckle up – and let’s talk about the legal.

CMS will pay more for assessment services.

Last year, CMS announced its decision to reevaluate CPT codes with the goal of shifting payments more towards Assessment and Management (E / M) services – which PT, OT and SLP rarely charge. In the rule proposed for 2021, CMS recognized that PT, OT and SLP rating services are similar to E / M codes (i.e. both require appraisal and management work) and have offered a modest increase in payment for these services.

CMS proposed to apply an increase in RVU (estimated at 28%) to the following codes: 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 92521, 92522, 92523 and 92524.

PT and OT payments will suffer a significant overall reduction.

Unfortunately, CMS’s plan to increase E / M payouts and review code comes at a price. In order to fund these changes, CMS proposes to reduce the conversion factor (i.e. the number by which CMS determines all CPT code payments) by 10.61%. The direct result is that Medicare PT and OT payments will experience a estimated reduction of 9% to come January 2021. CMS also clarified that the estimate of the 9% reduction already takes into account proposed increases in the payment of the therapeutic assessment.

There is a silver lining at the bottom of this roller coaster fall. By implementing the E / M cuts in this way, CMS has made it easier for Congress to allocate money to the Medicare budget. So directing advocacy to Congress at this time is essential.

PTs, occupational therapists and speech language pathologists will not receive permanent telehealth privileges.

Due to the rapid and widespread (and frankly successful) adoption of telehealth across the country, CMS has decided to continue paying for remote care services. However, under the rule proposed for 2021, CMS does not provide to extend permanent telehealth billing privileges to PTs, occupational therapists, or speech language pathologists, citing previous legislation that did not include rehabilitation therapists “on the statutory list of eligible remote site practitioners.”

CMS also proposed to omit therapy services entirely from the list of eligible telehealth services, which would prevent therapists from providing and billing a physician for telehealth incidents. CMS chooses to do so because it believes that “the addition of therapy services to the list of Medicare telehealth services could lead to confusion over who is authorized to provide and bill for these services when they are provided through the telehealth.

Other remote services

As part of this proposal, PTs, occupational therapists and speech language pathologists will be permitted to provide “brief online assessment and management services as well as virtual recordings and remote assessment services.” (Think of electronic tours, virtual recordings, and other remote management services.) Telephone services, however, were not included in the proposal.

To help rehabilitation therapists continue to provide remote services, CMS proposed to create two new G HCPCS codes that are similar to virtual registration codes, have the same value, and are specifically intended for clinicians who typically do not charge E / M services.


Due to the COVID-19 public health emergency, CMS adopted an interim policy that revised the definition of direct supervision, allowing providers to provide such supervision virtually (for example, via two-way video). CMS is to propose to extend this policy until the end of the public health emergency or on December 31, 2021.

PTAs and OTAs will be allowed to provide maintenance treatment.

Earlier this year, when CMS released its final rule on home health, he stated that PTAs and OTAs could provide maintenance treatment to Medicare beneficiaries in hospital settings (for example, SNFs or CORFs). To align Medicare policy at all levels, CMS proposed to allow PTA and OTA to provide maintenance treatment whatever the context:

“We do not believe that the maintenance therapy requirement reserved for the therapist is necessary in the case of outpatient physiotherapy or occupational therapy services, and rather we believe that it would be appropriate for an occupational therapist or physiotherapist to be authorized. to use professional judgment to assign the provision of maintenance therapy services to an OTA or PTA when it is clinically appropriate to do so. “

Students in therapy can help with the documentation.

In the proposed rule for 2021, CMS also clarified that therapy students are allowed to document in the medical record – provided the billing therapist reviews, verifies, signs and dates the record.

Rehabilitation therapists cannot charge for remote physiological monitoring codes.

CMS also clarified that Remote Physiological Monitoring (RPM) codes 99453, 99454, 99457, 99458 and 99091 are E / M services – which “can only be ordered and billed by physicians or non-physician practitioners ( NPP) eligible to bill Medicare. for E / M services. ”This ultimately means that PTs and occupational therapists will not be able to bill Medicare for these CPT codes.

MIPS will only change slightly.

Fortunately, the proposed changes to the MIPS program are not too complex. Let’s review the highlights! But first, if you need a MIPS reminder, check out this complete guide in the program.

MIPS Value Lanes

MIPS Value Pathways (MVP) are a “participation frameworkThat would unite the activities and measures of the MIPS program and remove the siled nature of the four categories. CMS initially planned to transition vendors to MVPs in the 2021 performance year. But, due to the COVID-19 pandemic, CMS grows its timeline and has no plans to implement any MVPs until 2022, at least.

Low volume threshold and category weighting

CMS has not proposed any changes to the low volume cutoff criteria, meaning that individual clinicians will still be mandated to participate in MIPS if they:

  • submit Medicare Part B claims for more than 200 unique beneficiaries,
  • submit Medicare Part B claims for more than 200 services (i.e. CPT codes), and
  • bill more than $ 90,000 in eligible expenses under the Medicare Part B program.

The agency also proposed to keep the MIPS category reweighting of 85% for the Quality Measurement domain and 15% for the Improvement Activities domain for PTs, Occupational Therapists and Speech-Language Pathologists.

Performance threshold

In recognition of the pressure exerted by COVID-19 on our country’s health system, CMS proposed to lower the performance threshold for the performance year 2021. If this proposal is finalized, MIPS participants would have to earn 50 points or more to achieve a neutral or positive adjustment (instead of the 60 points previously required). The extra performance threshold for outstanding performance is not expected to change from its current 85 points.

Quality category

The proposed rule described several changes to the sets of measures in the quality category. First, CMS proposed to add measures 283 and 286 (two measures of dementia) to the PT / OT specialty set and to remove measure 282 (also a measure of dementia) due to its similarity. with another measure. In addition, CMS proposed to add measure 134 (screening for depression) to the SLP specialty set.

Beyond that, CMS proposed “Substantial changes” in almost all clinical quality measures (LCQ) – most often reflected in the denominator of each measure. We will keep you informed as our MIPS experts analyze proposed (and possibly finalized) legislation.

You don’t like the content of the proposed rule for 2021? Keep your eyes peeled for advocacy efforts led by APTA, AOTA, ASHA, and WebPT.


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