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  • Home
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  • 2019 Medicare Physician Fee Schedule Changed to Therapy Services

2019 Medicare Physician Fee Schedule Changed to Therapy Services

27 Nov 2018 12:48 PM | Zachary Edgar (Administrator)

Payment for Outpatient PT and OT Services Furnished by Therapy Assistants

Beginning January 1, 2022, payment for services provided “in whole or in part” by a therapy assistant will be reduced to 85% of the Part B payment.

This applies to outpatient therapy services and providers that submit institutional claims for therapy services such as outpatient hospitals, rehabilitation agencies, skilled nursing facilities, home health agencies and comprehensive outpatient rehabilitation facilities (CORFs). The reduced payment rate is not applicable to outpatient therapy services furnished by critical access hospitals.

New PTA and OTA modifiers must be used beginning January 1, 2020.

Modifiers for Therapist Services

Revised GP modifier: Services fully furnished by a physical therapist or by or incident to the services of another qualified clinician – that is, physician, nurse practitioner, certified clinical nurse specialist, or physician assistant − under an outpatient physical therapy plan of care.

Revised GO modifier: Services fully furnished by an occupational therapist or by or incident to the services of another qualified clinician – that is, physician, nurse practitioner, certified clinical nurse specialist, or physician assistant − under an outpatient occupational

therapy plan of care.

Modifiers for Therapy Assistant Services

PTA Modifier CQ: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant.

OTA Modifier CO: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant.

Therapists and Assistants Working Together

The extent to which the modifiers apply to clinical scenarios in which the therapist and therapy assistant work together to furnish services collaboratively may be dependent on whether the therapy assistant’s services are furnished in the absence of the therapist, whose time could then no longer be attributed to that patient.

CMS has 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. We anticipate addressing application of the therapy assistant modifiers and the 10% percent standard more specifically, including their application for different scenarios and types of services, in rulemaking for CY 2020.

Functional Reporting Modifications

Discontinued as of January 1, 2019

Therapy KX Threshold Amounts

Increase the CY 2018 KX modifier threshold amount of $2,010 by the CY 2019 MEI of 1.5 percent and rounding to the nearest $10.00 results in a CY 2019 KX threshold amount of $2,040 for PT and SLP services combined and $2,040 for OT services.

The Targeted Medical Review Process

CY 2019, the MR threshold is $3,000 for PT and SLP services combined and $3,000 for OT services. Under the established targeted review process, some, but not all claims exceeding the MR threshold amount are subject to review. For information on the targeted manual medical review process, go to https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare FFS-Compliance-Programs/Medical-Review/TherapyCap.html.


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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