Therapists in the SNF (Skilled Nursing Facility) setting are starting out 2019 with a few less documentation requirements to worry about. Less? Now that’s a first! So what’s up for 2019?

The Final Rule {you’re starting to see the pattern that these Final Rules are never final, right?} released November 1st, 2018 by CMS included updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS). What services are furnished under the Medicare Physician Fee Schedule? You guessed it…. Medicare Part B.

What Do SNF Therapists Need to Know?

1- Discontinuation of Functional Status Reporting Requirements for Outpatient Therapy

  • Functional Limitation Reporting (FLR), a.k.a. G-Codes, will not be required for therapy Part B visits provided on or after 1/1/19
  • If your therapy software is still requiring these codes, it may be because software updates that trigger these codes have not been updated yet, or possibly your therapy software uses the G-Codes as a basis for outcome measure tracking
  • Medicare will allow these codes to continue to be reported on claims for now until software providers can update their systems
  • Chapter 15 of the Medicare Benefit Policy Manual {where Part B rules live} has not yet been updated with the Final Rule changes

2- Therapy Cap

  • The cap has been gone for 1 year and is not coming back! But…..
  • The Final Rule requires the use of the KX modifier to all therapy services that “would have exceeded the previous therapy cap amounts”
  • The Therapy Cap has now become the KX Modifier Threshold
  • KX modifier is needed on Part B claims for services over the “threshold” in order for the services to be paid by Medicare
  • New “threshold” for 2019 is $2040 for OT, $2040 for PT and Speech combined (up 1.5% from last years amount)
  • Payment will be denied of no KX once threshold is hit
  • **Important reminder and repeated for therapists again in the Final Rule**

By applying the KX modifier to the claim, the therapist or therapy provider is confirming that the services are medically necessary as justified by appropriate documentation in the medical record.

3- Manual Medical Review

  • Threshold continues at the same amount of $3000 until 2028 {Wow, Medicare is really thinking ahead!}
  • Review is not automatic. CMS is limiting reviews to “outliers” and those with questionable practice patterns

4- PT and OT Evaluation CPT Codes

  • Nothing new here…
  • After a long enough data collection period with the new PT and OT evaluation complexity codes, it was anticipated that a change in payment structure may be released. However, no changes were proposed in the recent Rule.

5- Reduction of Payment for Part B Services Provided by Assistants (PTA, COTA, OTA)

  • All therapy services on or after 1/1/20 provided in whole or in part by an Assistant will need to be billed using the new payment modifiers
    • New PTA Payment Modifier: CQ
    • New OTA Payment Modifier: CO
  • All therapy services on or after 1/1/2022 provided in whole or in part by an Assistant will have a payment reduction of 15%  applied

What does provided in whole or in part mean?

CMS is defining in whole or in part  as provision of  more than 10% of a therapy service by an assistant.  The Final Rule states that specifics to this point will be addressed in the 2020 Proposed and Final Rules. {This is an improvement from the Proposed Rule which defined in whole or in part as “any minute!”} By using the payment modifiers in 2020, CMS will have 2 years of data collection to assess potential revisions to the requirements.

What else did CMS add in this Section of the Rule?

In the discussion of Assistants, the Final Rule reiterates that Assistants “may not provide evaluative or assessment services, make clinical judgments or decisions; develop, manage or furnish maintenance program services.” This is important to point out because as of next year at this time, we will be identifying all assistant treatments on the billing claims (if >10% of the service).


Remember, these changes are for Part B therapy only, regardless of the setting. We are still waiting on the official updates to Chapter 15 of the Medicare Benefit Policy Manual, but the above changes are official from the Final Rule. So what will we see in the SNF setting with the changes above, in particular the changes related to assistants? We may see a shift in who assistants provide therapy to in the SNF; possibly a shift away from Part B and toward Part A and Managed Care to avoid the payment reduction. One would hate to think that some providers will take the time to figure out how to have assistants provide 9% of the therapy service to avoid the payment reduction……let’s hope not!

For now, we will go with the flow and see what change brings. Heaven knows we are used to it!

Any questions on the information, please submit them to our Just Ask Q&A Forum!

In Your Corner,


Dolores Montero, PT, DPT, GCS, RAC-CT, RAC-CTA

SNF Therapy & MDS Compliance Team

Links if you want to further explore this area

Article explaining Part B changes

Final Rule 11/1/18 – PDF Version (852 pages)

Chapter 15 – Medicare Benefit Policy Manual Rules for Part B

Chapter 15 – Section 220.4 – Functional Limitation Reporting – Info has not been updated to remove G Code requirement as of 1/1/19

Medicare Claims Processing Manual – Info for G Codes has not been updated as of 1/1/19

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