CMS released the Physician Fee Schedule (PFS) Final Rule, or the “Medicare Part B Rules,” outlining what kicks in 1/1/23. This 2,953-page document includes information on payment rate changes, new codes, supervision of assistants, telehealth and more! We highlighted the Medicare Part B rules that are most pertinent to therapy in the SNF setting.
Let’s take a look….
Changes for January 1st, 2023?
1. Rate Information
Rate cuts have been a constant for the last few years, and 2023 will be no different. CMS finalized a 4.4% decrease from CY2022.
The 4.4% cuts for CY2023 are in part due to the expiration of the 3% “intervention” from Congress that ends 12/31/22, and an additional 1.4% cut to maintain budget neutrality.
So, here we are again, just like the last 2 Novembers, waiting to see if the cuts will take place as is, or if there will be a Congressional intervention to soften the blow. Current legislation has been introduced to help offset the cuts by increasing the CF. [Supporting Medicare Providers Act of 2022 – (H.R. 8800] However, no action has been taken and 4.4% is what we can expect at the moment.
Cuts can be attributed to a decrease in the Conversion Factor (CF). This is a value that CMS modifies yearly, and is part of the formula that determines the dollar amount for each CPT code by converting Relative Value Units (RVU). The CF impacts all CPT Codes across the board. When the CF decreases, the overall payment rate for the CPT codes decrease, unless the RVU for a specific CPT code is increased enough to offset the CF drop.
The CF has not been trending in a favorable way over the past 4 years, hitting a 20-year low for 2023. The CF for 2023 is $33.06, dropping from $34.61 last year.
Did you know you can look up any CPT code and check the rate HERE ?
Other cuts currently in play?
- 15% cut for therapy services provided by assistants began in 2022 (CO/CQ modifiers)
- Multiple Procedure Payment Reduction (MPPR) of 50% to the Practice Expense of each CPT code for any subsequent unit of service performed after the first unit on the same day
- 2% Sequestration Cuts that were phased back in July 2022
- Potential return of the Statutory Pay-As-You-Go cuts (PAYGO) paused by legislation in 2022
2. Virtual Services and Telehealth
Virtual Services is the umbrella category where Telehealth lives. Virtual Services encompass Telehealth, E-Visits, Virtual Check-Ins and Telephone E/M services.
Therapists were not able to provide telehealth services prior to the Public Health Emergency (PHE) and are currently only able to provide telehealth now through waiver authority under section 1135(b)(8) of the Act.
The ability for therapists to provide telehealth services after the waivers and interim policies expire was further extended in March of 2022, when Congress approved an extension of telehealth services for an additional 151 days after the PHE ends. This extension was included in the Consolidated Appropriations Act of 2022, allowing telehealth to continue a little bit longer in the SNF and other settings.
View the Act here, with attention starting on page 1901.
In the Final Rule, CMS provided the updated list of Telehealth CPT Codes for the PHE duration. You can download the list here:
List of Telehealth Services for Calendar Year 2023 (ZIP) – Updated 11/02/2022
Of note, when viewing the list, even though some codes state “Available up through December 31, 2023,” therapist’s ability to bill for these codes will expire either PHE end + 151 days, or on 12/31/23, which ever comes first.
The legislation now with Congress, called the Expanded Telehealth Access Act [HR 2168/S 3193], if passed, would give CMS the authority to make the temporary PHE rules permanent for telehealth.
3. New Codes / Deleted Codes
Remote Therapeutic Monitoring:
Last year, 5 new codes were introduced for Remote Therapeutic Monitoring, as follows:
- CPT code 98975 ─ Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment
- CPT code 98976 ─ Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days
- CPT code 98977 ─ Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days [CMS referenced ARIA PT device]
- CPT code 98980 ─ Remote therapeutic monitoring treatment management services, physician/ other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes
- CPT code 98981 ─ Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes (List separately in addition to code for primary procedure)
In the Proposed Rule, CMS planned to create 4 new G-Codes, GRTM1, GRTM2, GRTM3 and GRTM4, of which, GRTM3 and 4 would replace the 98980 and 98981 codes above.
However, in the Final Rule, CMS did not proceed with the 4 new G-Codes, and instead, issued a clarification and finalized a new policy regarding the billing requirements for the continued use of the current RTM codes above. Effective 1/1/23, the RTM code billing requirement was clarified to allow general supervision. This aligns with the existing Medicare supervision requirement for PTA’s and OTA’s in the SNF setting of general supervision, though is unclear how this will impact the private practice/outpatient setting where the Medicare supervision rule is direct supervision.
CMS finalized 2 new codes for the management of chronic pain. Though CMS confirms these codes will only be used by physicians / physician extenders, PT and OT collaboration is mentioned in the code description, which may allow a window for advocacy for our services in the future.
- HCPCS code G3002: Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care coordination between relevant practitioners furnishing care (e.g., physical therapy and occupational therapy, and community-based care), as appropriate. Required initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month.
- HCPCS code G3003: Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month
4. Direct Supervision by Interactive Telecommunications Technology
Currently, due to the PHE temporary rule set, the Medicare rule around supervision has been modified to include providing direct supervision via audio-visual technology. The Proposed Rule discussed the possibility of making this permanent policy, thus removing the need for direct supervision for Medicare reimbursement, though CMS did not change anything in the Final Rule.
CMS reminds us that after December 31st of the year the PHE ends, pre-PHE rules for direct supervision would apply.
***Of note, this does not impact the SNF setting specifically as Medicare Part A and Part B in the SNF currently require “general supervision,” meaning a therapist does not need to be in the room or on site in order for an assistant to provide services. Medicare Part B supervision rules for Private Practice, however, are more strict, requiring “direct supervision.”
It is important that this rule is not confused with your State Practice Act requirements for supervision. Even though Medicare has temporarily relaxed the supervision regulation, if your State Practice Act for your particular therapy discipline requires on-site supervision, the Medicare rule is overridden.
The Stabilizing Medicare Access to Rehabilitation and Therapy Act (SMART Act), HR 5536, is current bipartisan legislation that would change the supervision requirement in private practice / outpatient settings from direct to general.
5. Modifiers and Manual Medical Reviews
CO and CQ Modifiers for Assistant Services
We are finishing up year 1 of the impact of the 15% payment reduction for therapy services provided by an assistant that meet the CMS definition of “in whole or in part,” and are coded with the CO or CQ modifier. There are no changes proposed in this area. If you need a refresher to ensure you are using the modifiers correctly, visit HERE.
KX Modifier Threshold
The “old” Therapy Cap is now disguised as the KX Modifier Threshold, and “threshold amounts” change yearly. The 2022 “threshold” is $2150 for OT, $2150 for PT and Speech combined. The Final Rule confirmed the CY2023 amount of $2,330. Continued use of the KX modifier is required for all therapy services that “would have exceeded the previous therapy cap amounts,” or claims will be automatically denied.
Manual Medical Review
The manual medical review threshold continues at the same amount of $3000 until 2028.
A review is not automatic when the $3000 is reached. CMS is using targeted reviews, limiting reviews to “outliers” and those with questionable practice patterns.
Important Links and Resources
Cuts, cuts and more cuts seem to be the theme for 2023…..and 2022…..and 2021…..
Remember, these changes are for Part B therapy only, and specific to the SNF setting. We teased out the parts of the Rule that applied to the SNF….so don’t worry about MIPS, Quality Measures or other rules specific to private practice!
As always, if you have any questions about the information or how it will impact you, send them to us here: Just Ask Q&A
In Your Corner,
Dolores Montero, PT, DPT, RAC-CT, RAC-CTA
SNF Therapy & MDS Compliance Team