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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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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status reporting data that would be collected may be even less purposeful because the Bipartisan Budget Act of 2018 repealed the therapy caps while imposing protections to ensure therapy services are furnished when appropriate.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. 


  • Medicare Proposed 2019 Physician Fee Schedule

    3 Oct 2018 2:04 PM | Zachary Edgar (Administrator)

    Outpatient PT and OT 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 CMS to establish a new modifier by January 1, 2019 and detail CMS's plans to accomplish this in the proposed rule.

    CMS is proposing to establish two new therapy modifiers – one for PT Assistants (PTA) and another for OT Assistant (OTA) – when services are furnished in whole or in part by a PTA or OTA. These are to be used in conjunction with the three existing therapy modifiers that have been used since 1998 to track outpatient therapy services that were subject to the therapy caps. The new therapy modifiers for services furnished by PTAs and OTAs are not required on claims until January 1, 2020.


  • Updates to North Carolina Medicaid

    18 Sep 2018 2:54 PM | Zachary Edgar (Administrator)

    Prior Approval changes to NC Medicaid coverage for adults.

    Removal of diagnosis specific coverage and replaced with general prior authorization requirement and service limit:

    Prior approval is required at the start of all treatment services. 

    Detailed information and instructions for registering and submitting requests is available on The Carolinas Center of Medical Excellence (CCME) website https://www.medicaidprograms.org/NC/ChoicePA The provider shall submit a request to DHHS utilization review contractor to start the approval process. Please note that approval, if granted, is for medical approval only and does not guarantee payment or ensure beneficiary eligibility on the date of service. 

    The first prior approval request within a calendar year shall be for no more than three therapy treatment visits and one month. The PA review vendor will authorize these three treatment visits to begin as early as the day following the submission of the PA request. Any subsequent PA may be obtained for up to 12 therapy treatment visits and six months. A beneficiary can receive a maximum of 27 therapy treatment visits per calendar year across all therapy disciplines combined (occupational therapy, physical therapy and speech/language therapy). 

    Each reauthorization request must document the efficacy of treatment.


  • Massachusetts Physical Therapy

    20 Aug 2018 4:08 PM | Zachary Edgar (Administrator)

    Content added:

    Massachusetts Medicaid Coverage of Physical and Occupational Therapy 

    MA PT Scope of Practice

    MA PT Direct Access and Referrals

    MA PT Supervision and Delegation

    MA PT Assistants

    MA PT Aides

    MA PT Students

    MA PT Temporary Permits

    MA PT License Exemptions

    MA PT Licensure by Endorsement

    MA PT License Reinstatement 

    MA PT Documentation 

    MA PT Identification and Notifications

    MA PT Facilities 

    MA PT Board Fees

    Mass Medicaid and Workers Comp Fee Schedules 


  • Florida OT Updates

    14 Aug 2018 4:09 PM | Zachary Edgar (Administrator)


  • California Physical Therapy

    13 Aug 2018 3:09 PM | Zachary Edgar (Administrator)

    Content added 8/13/2018

    California Medicaid Coverage of PT and OT

    CA PT Continuing Education

    CA PT Scope of Practice

    CA PT Electromyography

    CA PT Topical Medications

    CA PT Direct Access and Referrals 

    CA PT Assistants

    CA PT Aides

    CA PT Students

    CA PT and PTA Graduates 

    CA PT Documentation 

    CA PT Advertising

    CA PT Unprofessional Conduct

    CA PT Board Fees

    CA Fee Schedules



  • Alabama Updates

    13 Aug 2018 2:17 PM | Zachary Edgar (Administrator)

    Added additional content to both Alabama physical and occupational therapy sections along with Alabama's Medicaid coverage of PT and OT. 

  • Welcome to Therapy Comply

    14 Nov 2017 11:32 AM | Zachary Edgar (Administrator)

    We are celebrating the launch of Therapy Comply this week.  This site's goal is to provide physical and occupational therapists with key state and federal regulatory information.  This will include detailed surveys on state law, for example: PTA/Aide supervision, scope of practice, continuing education requirements, direct access, disciplinary information, license provisions, and more.  The site will also include guides on Medicaid, Medicare, Tricare, and workers' compensation.  We hope the site will serve your compliance needs and improve your ability to provide care to your patients.  

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About Me

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

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