The Centers for Medicare and Medicaid Services (CMS) released the final rule for calendar year 2019. Qualified Clinical Data Registries, Merit-based Incentive Payment System, Functional Limitation Reporting, KX modifiers, Telehealth, Coding for Assistants and more!
It’s official! The MIPS measures stewarded by Focus on Therapeutic Outcomes are the only patient reported outcome options in the Physical Therapy/Occupational Therapy Specialty measure set for the 2019 performance period! Individual MIPS eligible clinicians are required to report at least 6 quality measures including one outcome measure. FOTO measures are also high priority measures which help the MIPS eligible earn bonus points when they are submitted. FOTO is also a Qualified Clinical Data Registry, which means that you may use FOTO to report your measures.
I’m getting ahead of myself. Let me back up and begin with a bit of structure so you will better understand where I am acquiring the information.
CMS released the Final Rule (unofficial version; Nov 23 is anticipated date for publication of official version) “Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements; Quality Payment Program; Medicaid Promoting Interoperability Program; Quality Payment Program–Extreme and Uncontrollable Circumstance Policy for the 2019 MIPS Payment Year; Provisions from the Medicare Shared Savings Program–Accountable Care Organizations–Pathways to Success; and Expanding the Use of Telehealth Services for the Treatment of Opioid Use Disorder under the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act“. Like the proposed rule, the final rule is pages and pages long. I have not thoroughly read the 2,378 page document. I’m sharing the highlights that most of you are probably interested in knowing.
Many in the rehabilitation industry will not be happy with this next upcoming change for calendar year 2022. There will be a new payment model implemented when services are furnished by a physical therapist assistant or an occupational therapist assistant. This change will affect all outpatient services including: outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities. New payment modifiers will indicate if 10% or more of the service was provided by a physical therapist assistant or an occupational assistant. A CQ modifier indicates that the outpatient services included care provided by a physical therapist assistant. A CO modifier indicates that the outpatient services included care provided by an occupational therapist assistant. The use of the payment modifier will begin in 2020. Beginning in 2022, the payment modifier will trigger a 15% reduction in payment in the allowed amount for the procedure compared to services provided by a physical or occupational therapist. The final rule continues to use the GP, GO, and GN modifiers to indicate services were delivered under a physical therapist, occupational therapist or speech-language pathologist plan of care.
Happy dance time: the mandatory requirement to include functional limitation and severity modifiers dies January 1, 2019. You will no longer be required to submit this information on claims for payment of services.
Telehealth was not expanded as an option to include physical therapists, occupational therapists, or speech-language pathologists.
For 2019 you will continue to use the KX modifier. The KX modifier threshold is determined annually by the Medicare Economic Index. For 2019 the KX modifier needs to be applied at $2,040. If a patient continues to require medically necessary services after payment for services has reached $2,040 the KX modifier is required. Without the KX modifier the claim will be denied. Also, until 2028 the medical review threshold for combined speech-language pathologists and physical therapists is $3,000 and for occupational therapists $3,000. The targeted medical review continues where not all claims will be subject to review.
Changes in Center for Medicare and Medicaid Services Quality Payment Program Year 3 that will potentially affect rehabilitation providers. In 2019 the Merit-based Incentive Payment System (MIPS) includes physical therapists, occupational therapists, qualified speech-language pathologists, qualified audiologists, clinical psychologists, and registered dietitians or nutrition professionals in the list of MIPS eligible clinicians. MIPS eligible clinicians must submit Medicare B claims with their National Provider Identifier (NPI). In other words, the performance of a MIPS eligible clinician has to be tracked. If a MIPS eligible clinicians practices at facility-based outpatient therapy clinics or skilled nursing facilities, then the MIPS eligible clinician really isn’t MIPS eligible because claims will not have the clinician’s individual NPI.
For MIPS eligible clinicians, participation in MIPS may not necessarily be mandatory. Mandatory MIPS participation is based on two sets of claims data. The first data set comprises October 1, 2017 through September 30, 2018. The second data set comprises October 1, 2018 through September 30, 2019. The data is analyzed to determine if the MIPS eligible clinician meets the low-volume threshold, has a non-patient facing status, has a small practice status, or has a hospital-based or ambulatory surgical center-based status.
MIPS eligible clinicians are EXCLUDED from MIPS if they meet one or more of the low-volume threshold criteria:
* Had claims submitted for <200 Medicare Part B-enrolled patients
* Received <$90,000 payment for services for Medicare Part B-enrolled patients
* Provided <200 professional services for Medicare Part B-enrolled patients
I’m all about the easy button. If you are confused about your quality payment program status, I can share two sites that will help you. If you are like me, you don’t have your NPI memorized. Your first step to learn if you are mandated to participate is to know your NPI number. You can find your NPI number here if you search by your name and state of practice. Copy your number and then paste it in this site. As I write this, 2019 status is currently not available.
In the event that you are not mandated to report information for MIPS, that doesn’t necessarily mean that you do not have the opportunity to opt-in and report data. If you meet or exceed one of the low-volume threshold criteria, you may opt-in to MIPS. Beginning with the 2021 MIPS payment year (i.e. 2019 performance year), if a MIPS eligible clinician exceeds at least one of the low-volume threshold criteria chooses to report on measures and activities, the clinician is treated as a MIPS eligible clinician.
I think I probably need to clarify a few terms. The 2021 MIPS payment year utilizes the information reported from January 1, 2019 through December 31, 2019. As you can see, the payment year is 2 years after the reporting year.
We now have a slew of new terms revolving around the collecting and submitting of quality and performance measures. The type of measures collected include: eCQMs; MIPS Clinical Quality Measures (MIPS CQMs); QCDR measures; Medicare Part B claims measures; CMS Web Interface measures; the CAHPS for MIPS survey; and administrative claims measures. You will need to be aware of which submitter type and which submission type you will use if you report. Small practice status affects the options for MIPS reporting. Small practice status is defined as having a tax identification number associated with <15 NPI. Small practices can use Medicare B claims to submit quality measures data. If you are not considered a small practice, then you will need to consider various options for submission. The easiest submission process would include a submitter type that is a third party intermediary that submits directly computer-to-computer; this “end-to-end” type of reporting may result in bonus points. As mentioned earlier, FOTO is a Qualified Clinical Data Registry and can submit your measures in an end-to-end mode.
You will have some wiggle room when it comes to the completeness of your data submissions. The requirement is to submit data on at least 60% of your patients.
The MIPS program consists of 4 categories: quality performance, cost performance, improvement activities performance and promoting interoperability performance. Each of these categories are weighted for a final score.
The Final Rule shared the specialty measure set of quality measures for physical therapists and occupational therapists on page 2290-2292. The quality measures are very similar to the previous Physician Quality Reporting System (PQRS). The proposed quality measures are of two measurement types: process and outcome. Process measures comprise the bulk of the specialty measures. The measures address body mass index, documenting current prescribed and over-the-counter medications along with supplements, assessing pain and addressing pain, and assessing function. The list of outcome measures for physical therapists and occupational therapists only includes seven NQF endorsed patient reported outcomes measures that are stewarded by Focus On Therapeutic Outcomes, Inc. (FOTO). These measures are considered MIPS clinical quality measures. Explore outcomes measures in this CMS tool. MIPS eligible clinicians opting-in and those required to participate will need to report on outcomes.
I know the FOTO team has been reviewing the Final Rule and are making preparations to assist MIPS eligible clinicians to meet the quality indicators. I’m sure you’ll hear more from FOTO in the upcoming weeks.
Until next time,