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Medicare 2019 Final Physician Fee Schedule

6 Nov 2018 11:53 AM | Zachary Edgar (Administrator)

Discontinue Functional Status Reporting Requirements for Outpatient Therapy

Since January 1, 2013 as required by the Middle Class Tax Relief and Jobs Creation Act of 2012, all providers of outpatient therapy services have been required to include functional status information on claims for therapy services. CMS implemented a system that collects data using non-payable HCPCS G-codes and modifiers to describe a patient’s functional limitation and severity at periodic intervals during outpatient therapy services. In response to the Request for Information on CMS Flexibilities and Efficiencies that was issued in the CY 2018 PFS proposed rule, CMS received comments requesting burden reduction related to the functional status reporting requirements.

The data from the functional reporting system was to be used to aid CMS in recommending changes and reforming of Medicare payment for outpatient therapy services that were subject to the statutory therapy caps. Going forward, the functional status reporting data that would be collected may be even less purposeful because the Bipartisan Budget Act of 2018 repealed the therapy caps while imposing protections to ensure therapy services are furnished when appropriate. As a result, CMS is finalizing our proposal to discontinue the functional status reporting requirements for services furnished on or after January 1, 2019. 

Outpatient Physical Therapy and Occupational Therapy Services Furnished by Therapy Assistants

The Bipartisan Budget Act of 2018 requires payment for services furnished in whole or in part by a therapy assistant at 85 percent of the applicable Part B payment amount for the service effective January 1, 2022. In order to implement this payment reduction, the law requires us to establish a new modifier by January 1, 2019 and CMS details our plans to accomplish this in the final rule. 

CMS is finalizing our proposal to establish two new modifiers – one for Physical Therapy Assistants (PTA) and another for Occupational Therapy Assistants (OTA) – when services are furnished in whole, or in part by a PTA or OTA. However, CMS is finalizing the new modifiers as “payment” rather than as “therapy” modifiers, based on comments from stakeholders. These will be used alongside of the current PT and OT modifiers, instead of replacing them, which retains the use of the three existing therapy modifiers to report all PT, OT, and Speech Language Pathology services, that have been used since 1998 to track outpatient therapy services that were subject to the therapy caps. CMS is also finalizing a de minimis standard under which a service is furnished in whole or in part by a PTA or OTA when more than 10 percent of the service is furnished by the PTA or OTA, instead of the proposed definition that applied when a PTA or OTA furnished any minute of a therapeutic service. The new therapy modifiers for services furnished by PTAs and OTAs are not required on claims until January 1, 2020. 


About Me

Zachary Edgar JD, LLM is the managing partner for Therapy Comply.  Zachary is a healthcare attorney that specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

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