Blue Sky Therapy Blog

Physician Fee Schedule Final Rule for Skilled Providers

The Centers for Medicare and Medicaid Services (CMS) released a Physician Fee Schedule (PFS) final rule that became effective January 1, 2021. This includes updates on policy changes for Medicare payments and other Medicare part B policies.

We combed through the near 2,000-page document (1,994 pages to be exact) to provide the most useful information for skilled providers. Here is a link to the official document should you desire to do some leisurely reading. Although initially it seemed pretty grim with a 9% cut looming, the actual takeaways we gleaned from the 2021 Physician Final Rule are a little more positive than originally proposed.

Increased RVUs for evals/re-evals and Maintenance therapy by PTAs.

At least they increased the Relative Value Unit (RVU) for some CPT codes. Evaluations and re-evaluations, to be exact, will have a higher RVU despite the reductions to many other commonly used Current Procedural Terminology (CPT) codes with more info on that below. Clearly CMS is moving towards placing a higher value on therapist-only provided services. With a higher RVU, you can expect higher reimbursement for the 3 physical therapy evaluation codes and 1 physical therapy re-evaluation code for the evaluations completed in your skilled facilities under Medicare Part B.

Physical and Occupational Therapists should be well-versed in coding evaluation complexity and re-evaluations appropriately. Here is a quick guide from the American Physical Therapy Association (APTA) on appropriate selection of evaluation complexity:

Additionally, CMS granted physical therapists the discretion to delegate the performance of maintenance therapy to a physical therapy assistant as clinically appropriate. As there are no special CPT codes for maintenance therapy under part B, when billing for maintenance care, you will still utilize the CPT code(s) that most accurately reflect the skilled interventions provided. You do need to ensure the service is properly documented as maintenance vs restorative per Medicare guidelines.

Physician Fee Schedule cuts.

Although rehab providers expected an average reduction of 9%, through a strong grassroots effort of advocacy and the introduction of additional legislation, we were able to successfully minimize the reduction. This collaborative effort of advocacy demonstrates the importance of making our voices heard! Thankfully, Congress passed legislation reducing the proposed average Medicare payment reduction for rehab services from 9% to an average of 3.6% and extended the pause on the sequestration reduction of 2% till April 1, 2021. More details on the reduction from the APTA can be found here:

This reduction might not be as significant as originally thought, but we still need to look ahead at the future and avoid complacency to stop the continued reduction in reimbursement for the services that our patients need. Continued reductions will limit access to care for our patients due to the negative impact on rehab providers in the post- acute space.

Frequently used CPT codes for OT/PT/ST therapy reflect anywhere from a 4% -13% reduction with the average reduction for all codes being 3.6%. Some of the most commonly used CPT for therapy with the largest reduction include: 92507 - speech therapy, 97110 - therapeutic exercises and 97530 - self- care management training to name a few.

Strategies to help minimize the impact of the reductions revolve around coding best practices. Be proactive with your coding, as coding should always be accurate and reflect the service provided. Ways to ensure your coding is appropriate is by completing audits to ensure clinical compliance and utilizing your billing entity, whether in-house or a third party, to provide analysis of code usage and reimbursement trends. You need to ensure the billing entity stays up-to-date with the latest coding guidelines per the National Correct Coding Initiative (NCCI) edits and regulations found here:

While the 2021 Physician Fee Schedule reductions were not as significant as originally thought, we need to look ahead to the proposed 15% cut to assistant-provided services proposed for 2022. This likely could happen and will AGAIN reduce your reimbursement for services provided. While 2022 may seem far off, it will be here before we know it! What we have seen in 2021 is a strong predictor that what is proposed usually comes to fruition in some form. Stay tuned for more……

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