Episode 19
Allison Jones: Good morning, good afternoon, and good evening, and welcome to the Therapy Matters Podcast, your one-stop resource for expert insights and advice on everything therapy and rehab. I’m your host, Allison Jones, and today, I’m joined by a panel of distinguished guests from Raintree. I’m pleased to welcome Veda Collmer, General Counsel and Chief Compliance Officer, Kathryn Rigda, Director of Product Management, and Kaitlin Beal, Regulatory Architect.
Ladies, thank you for joining me today.
Veda Collmer: Thank you.
Kathryn Rigda: Thank you.
Kaitlin Beal: Thank you.
Allison Jones: Well, it’s great to have you guys here. Today, we’re diving into a very important topic for clinics: the Medicare Physician Fee Schedule final ruling. Specifically, we’re looking at what it means for your clinic. We have a lot to unpack, so I won’t waste any time. We’re just going to jump right into my questions.
First up, Veda. For those who may not be familiar with the Medicare Physician Fee Schedule, can you give us a quick summary of the final rule and its purpose?
Veda Collmer: The Medicare obviously was created by Congress, but they can’t manage it, and the Centers for Medicare & Medicaid Services manages it. In 1992, they created the Physician Fee Schedule as a way to start setting those reimbursement fees. Now back then, Medicare was all fee for service. We all know that Medicare is migrating to value-based care. So every year, the Centers for Medicare & Medicaid Services releases updates to their fee physician or their fee per visit schedule. That also includes any pricing on their CPT codes. The new rules also include updates to value-based programs such as MIPS.
Allison Jones: One of the key components of the physician fee schedule is the Medicare Part B conversion factor. Kathryn, can you tell me what the decision was for this year and how that impacts rehab therapy?
Kathryn Rigda: The conversion factor is one of the elements that Medicare uses to calculate the final payment for various CPT codes. Because Medicare has a neutral budget requirement, they have to make adjustments to offset those changes whenever they make changes to the fee schedule. This year, the final rule implemented a 3.4% reduction in the conversion factor for 2024. This will impact more than 27 specialties, which does include therapy, with a corresponding reimbursement reduction. Unfortunately, now that the final rule has been published, the only way we can make any changes is for Congress to step in and act.
Over the last three years, they have acted at the last minute to neutralize the conversion factor cuts for that current year, but each year has been a temporary measure just for that current calendar year. This year, we did have the passing of the temporary government funding bill earlier in November. So we are not anticipating any action towards addressing the conversion factor cuts until January of 2024. We do encourage all of our providers and patients to contact your local legislatures and professional organizations to voice their opposition to these cuts while we still have that window of opportunity.
Allison Jones: Absolutely. Your voice matters. Kathryn, some other notable changes came down in the final ruling for therapy. Can you speak to those?
Kathryn Rigda: There were some fairly significant changes in therapy. One is a correction to a prior mistake from CMS, so it’s always nice when they can make a correction that impacts a therapist providing telehealth services in an institutional setting.
What this will do is allow our PTs in our institutional services to continue to participate in providing telehealth services using the 95 modifier through the extension that’s currently in place through the end of 2024. Some of the other changes that we also saw were some changes to the remote therapeutic monitoring codes where our treatment management codes 98980 and 98981; while those will continue to be based on time spent performing the actual monitoring, they remove the requirement for those codes also to require 16 days of active data collection. So that’s going to make it simpler for providers to determine when a patient is appropriate to build those codes for remote therapeutic monitoring.
We had a few changes with some new codes that are now available for therapists to bill for. PT, OT, and SLP now have the opportunity to bill for caregiver codes, allowing therapy providers to bill for individual and group caregiver training when the patient is not present, which has historically not been permitted. There was also a little bit of positive movement regarding the supervision of PTAs. While we did get the finalization of general-only supervision for remote therapeutic monitoring in any setting, we also got an extension of virtual supervision for PTAs and OTAs through the 2024 year. Still, we did not get any additional permanent changes to the requirements for direct supervision of PTAs in private practice. There was lots of discussion there, so we’re hoping that that’s something that will come in the future.
Allison Jones: Excellent. There is some good news about some of those changes. That’s great to hear.
Kaitlin, the final rule also evaluates changes to the merit-based incentive payment system, more commonly known as MIPS. Can you tell me what MIPS is?
Kaitlin Beal: MIPS originated back in 2017. CMS took three historic programs, the PQRS program, the Value-Based Modifier program, and the Meaningful Use program, and sunset those and created this new MIPS program under the MACRA legislation. The purpose is to score clinicians for their Medicare payment adjustment, whether that be a negative adjustment, neutral, or positive, and they are scored in four areas: quality, improvement activities, promoting interoperability, and cost.
Allison Jones: What does that mean when you say negative or positive? Can they get more or less of an incentive?
Kaitlin Beal: It’s written in the legislation that clinicians can receive upwards of a 9% positive payment adjustment. We have not really seen that since the program originated. However, we have seen negative, neutral payment adjustments, meaning clinicians will owe CMS money down to a -9% penalty. Again, the program is budget neutral, so it’s monies are paid in allocated monies earned to other clinicians. That’s really what that means at a high level.
Allison Jones: Okay. Great. Thank you. Veda, there were some other notable changes to the MIPS program this year. Can you give us a high-level overview of some of those changes?
Veda Collmer: As Kaitlin mentioned, MIPS has always had four categories. However, rehabilitation providers only had to participate in two categories: quality measures and improvement activities. Before this year, the promoting interoperability category was reweighted so that they were not scored against the rehabilitation therapist. Then there were no cost measures that applied to rehabilitation therapists.
But this year, that has changed. With the final rule, CMS requires rehab therapists to participate in promoting interoperability, and one of the foundational requirements is the adoption of a certified electronic health record. Then there are other requirements and participation in the cost measure. The cost measure category is slightly different because there aren’t measures you report to CMS. They collect information on the background. But now, there’s a low back pain measure that they will start collecting data on and evaluating costs, which may result in an incentive for rehab providers in the future or a downward adjustment. There was also the creation of a second path for MIPS called the MVP Pathways. It’s been a big year for changes.
Allison Jones: Veda, let me ask you, why do we think some of these changes are happening now?
Veda Collmer: CMS and Congress have set this vision that they want all healthcare providers to begin collaborating, which means sharing data. Working in silos and not communicating is not cost-effective, and it doesn’t provide good quality care. If providers adopt electronic health records, connect all those records, and start sharing data, then the cost will be better, the healthcare will be more efficient, and patients will get better quality care. That’s the big vision.
Requiring all MIPS-eligible clinicians to participate in promoting interoperability means that now CMS can start to encourage all types of providers to connect and to share data, but you can’t connect disparate systems. You want to make sure that you have systems that have structured data sets and that these systems also don’t introduce security issues, which is where the certification comes in.
In terms of the MIPS MVP Pathways, CMS is trying to create subsets of data reporting so that clinicians aren’t scrambling around looking for quality measures and their reporting methods are more efficient. This is the future of MIPS, which is the MIPS value pathways.
Allison Jones: Kathryn, Veda was talking a little about promoting interoperability and some of the changes that have occurred here. It’s no longer reweighted. What are the requirements for successfully attesting to PI or for PI?
Kathryn Rigda: This is a big change in the therapy world because it’s something that most of our therapy providers have not previously participated in. You have to think about promoting interoperability as really all focused on the safe and secure transfer of patient-related health data between organizations and providers to improve continuity of care and patient safety. That’s the big-picture goal that CMS is trying to encourage with this.
Multiple components must be combined to allow you to report promoting interoperability successfully. The first section of the category is a series of attestations relating to safety and general interoperability. The organization has to complete a security risk analysis. There’s an annual safety self-assessment using the safer guides that have been published by CMS and shared that all have to be completed, and the utilization of a certified EHR to make sure that all of that data being transferred is being transferred securely and in a readable format.
But from there, it gets a little bit more broken down into four areas that are measured and scored. Four main objectives have to be completed if they’re within the provider’s scope of practice. The first is e-prescribing, which most of our therapy providers are not eligible for. They would be excluded from that section because it’s outside their scope of practice. They’re not prescribing medications. In the next section, our objective is health information exchange, which is a provider-to-provider exchange of health-related data.
People can opt-in or report this section in a couple of different ways. They can use participation with a bidirectional data exchange using an HIE or a health information exchange platform. There’s also the option to utilize and to support electronic referral loops by sending and receiving electronic summaries of care documents. While most of our therapy providers don’t send formal referrals, what we’re seeing in the industry is that because we are accepting referrals from our physicians, the physicians are opting to send these referrals in by using their transition of care documents so that the physicians can meet their requirements.
By receiving those requirements, we’re helping our physicians meet their requirements. The providers must then reconcile the information against patient safety, ensuring everything is completed inside the incoming provider or the receiving provider’s documentation. That’s the health information exchange. While you’re not maybe referring, our therapy providers are definitely accepting and receiving referrals.
The third objective in promoting interoperability is provider-to-patient exchange. That’s about providing our patients access to their health information, which is typically done using a safe and secure patient portal. The last objective is to exchange public health and clinical data. That requires providers to coordinate and report relevant health data to their public health registry. Again, many therapy providers might be exempt from this based on their scope of practice, but it’s entirely based on the individual jurisdiction. So we highly recommend that groups that are reporting promoting interoperability check into their local area and what are the requirements of their local health jurisdiction so that they can make sure that if they’re required to submit data for specific health items that they are doing that.
Allison Jones: Thank you. Kathryn, one of the requirements for promoting interoperability is that you have to use an ONC-certified EHR. Why is that such a big deal?
Kathryn Rigda: It’s a big deal because that certification means that EHR has undergone rigorous testing to ensure that their data is safe and secure. It’s being transmitted appropriately in all appropriate formats and using standardized formatting that can be read and accepted by other certified EHRs. Why it’s important to our providers is that promoting interoperability cannot be reported if you are not using a certified EHR.
Promoting interoperability makes up 25% of your total MIPS score. If you cannot report PI because you’re not using that certified EHR, then you are automatically taking a zero in that category, which is a significant reduction to your potential score, and, as Kaitlin talked about earlier, your potential incentive reimbursement.
Allison Jones: If a practice is not on a certified EHR today, how can they rectify it? How much time do they have to get on that certified EHR?
Kathryn Rigda: The promoting interoperability category has to be recorded for 180 days out of the calendar year. You have to use the certified EHR for the entirety of that 180 days, starting at the beginning of July 2024 and taking you through the end of the calendar year. There is time to make sure that you’re meeting those requirements and do transitions or connect with your EHR to ensure they have all of the components you require.
Allison Jones: Okay, excellent. Thank you. Veda, I’m going to switch over to you. There are such things as hardship exceptions that practices or clinics can apply for. Can’t practice just apply for a hardship exception in this case if they don’t have a certified EHR?
Veda Collmer: Well, technically, they can. Those hardship exceptions are available to them. But keeping in mind that CMS’s goal is interoperability, this is what they want, and they’re heavily pushing for this because it will provide better care. They will construe the requirements for the hardship exception very narrowly. There are two. One is the extreme and uncontrollable circumstances, and the second one is the promoting interoperability hardship exception. Both of them, if you apply, you’ll present facts as to why you qualify for that exception, and then they’ll review those facts.
I just wanted to quickly look at the requirements for promoting interoperability. Under this hardship exception, they list some of the factors that would render you a qualified candidate for the hardship exception, ones that, for some reason, your EHR was decertified during that reporting period, or you had internet issues, severe internet issues, or there was a terrible disaster that affected your practice. CMS says on its website that it will not consider the unavailability of a certified EHR qualifying for the hardship exception. They have already said that they will not consider that a factor.
The other point to remember is that hardship exceptions are granted each year, so you’d have to apply each year and take the risk that you’re not granted that hardship exception. There is a belief that CMS does cap the number of hardship exceptions they will grant for a provider, so it’s not guaranteed that you could do that every year.
Allison Jones: That’s great advice. It’s good to know that. Kaitlin, there is an alternative way to meet MIPS reporting requirements. Can you speak to the MIPS value pathways and the development of MVP reporting for PTs and OTs?
Kaitlin Beal: There have always been two paths to participating in MIPS. There’s been traditional MIPS and then alternative payment models. CMS has added another voluntary way to report called MIPS Value Pathways. A therapy-specific MVP called Rehabilitative Support for Musculoskeletal Care is available. What they’ve done with MVPs is they’ve made it more clinically relevant to the providers that would report under the MVP.
Traditionally, there is a requirement to report six quality measures. Then in the MVP, there is a minimum requirement of four quality measures, still two medium-weighted or one high-weighted improvement activity, the same promoting interoperability reporting requirements, and then the addition of one cost measure for low back pain. That is scored on administrative claims.
Allison Jones: Excellent. Thank you. Veda, why are these MVPs important?
Veda Collmer: CMS has said in the final rule that they plan to sunset traditional MIPS and move all participants, all eligible clinicians, to the MVP Pathways by 2030. One day, this reporting method will not be voluntary, so this is an opportunity for rehab providers to voluntarily report and test their skills in this area and identify issues early on. The other way that MVPs are important is that it’s hard to find measures for rehab therapists to report on, especially when the measures get topped out. They’re sunset or decommissioned; the therapists must find other measures. CMS is trying to make, to group measures into certain categories and make things easier for providers so that their reporting requirements are more efficient.
Allison Jones: This is an opportunity for therapy and rehab to start considering MVPs as a way of reporting moving forward before that 2030 deadline.
Veda Collmer: This is the way in the future, yes.
Allison Jones: Kaitlin, there are also some changes to consider around quality measures and improvement activities. Can you tell me a little bit more about those?
Kaitlin Beal: I think the first thing to mention regarding quality measures is that they have increased the data completeness requirement. The data completeness requirement in 2023 or for this reporting year is 70%, and they finalized to increase that to 75%. For all data collected on quality measures, the data completeness, meaning it meets the numerator, is 75%. That increase is very important.
The other change that we saw was that CMS elected to remove Measure 128, the BMI measure, from traditional MIPS reporting. This means that the measure is still available for MVP reporting but is not part of traditional MIPS. That’s a pretty big change. CMS added a handful of new measures, but we’re waiting on final coding updates to see which ones fall into the therapy category.
There are five new improvement activities for 2024. I think the one that is most notable since we’ve talked about MVPs is that clinicians can attest to a new improvement activity that they have adopted and are in practice for the MIPS value pathway. There’s a new improvement activity and a way to attest to the MVP usage.
Allison Jones: Excellent. Thank you. This topic is complex, and we’re just covering the tip of the iceberg here. We can only cover so much during this podcast, but we have some great resources available for those interested in learning more. We are launching a resource center on our website, raintreeinc.com. You can find it under our resources navigation tab. This will have webinars, blog posts, podcasts, and lots more for you to dig into and expand your knowledge. We do encourage you to go visit the site take a look, and consume all of that knowledge.
But we are out of time for today. I want to thank Veda, Kathryn, and Kaitlin for joining us and sharing this great information. There’s so much to consume and learn about the final ruling, MIPS, and the MVPs.
Thank you, and thank you to our audience for tuning in to the Therapy Matters Podcast, your one-stop resource for expert insights and advice on everything therapy and rehab. We look forward to seeing you on the next episode. Thanks so much.
Veda Collmer: Thank you.
Kaitlin Beal: Thank you.
Allison Jones: Thanks for listening to Therapy Matters. Do you like the podcast? Give us a five-star rating, subscribe, and tell all your friends about the show. Want to be a guest or know someone who would be a great guest speaker? Contact me at allison.jones@raintreeinc.com. That’s A-L-L-I-S-O-N.jones@raintreeinc.com.
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