2022 CMS Changes to PT/OT/SLP Billing


KX Modifier Threshold

For 2022 this KX modifier threshold (Therapy Cap Limit) amount is $2,150 for PT and SLP services combined, and. $2,150 for OT services.

It is $2,110 in 2021. Medicare has increased $40 in 2022.

The medical review (MR) threshold is $3,000 for PT and SLP services and $3,000 for OT services. 

 

Cuts to Therapy Services

In the final rule, CMS slightly mitigated the cuts set to return in 2022 stemming from the 2021 Evaluation and Management code changes by transitioning the clinical labor pricing policy over 4 years. With the additional 3.75% funding Congress provided for 2021 coming to an end, the conversion factor for the 2022 fee schedule is dropping to $33.59 from $34.89 in 2022.

 

MIPS deleted measure in 2022

Quality Measure 154, Falls Prevention, has been deleted from the MIPS program beginning in 2022.

 

MIPS will be replaced by MIPS Value Pathway program.

The traditional MIPS was designed to reward eligible physicians with higher payments for improvements in quality, cost, specified improvement activities, and promoting interoperability. The proposed MVP program would adjust measures used in MIPS to simplify the program, create more meaningful rewards for clinicians providing high-quality care, and promote greater patient engagement. CMS is delaying the implementation of the MVP program to CY 2023, which will allow physicians, Medicare Administrative Contractors, and


Increase Reimbursement for OT evaluation code

CMS has announced an increase of $2 per evaluation code beginning in 2022.


15% Payment Cut for PTA/OTA services

CMS has already introduced two modifiers for PTA’s and OTA’s as follows;

CQ modifier:  PT services furnished in whole or in part by PTAs and

CO modifier: OT services furnished in whole or in part by OTAs.

 

For CY 2020, CMS established a de minimis standard for such services – meaning that portions of a service furnished by the PTA/OTA independent of the physical therapist/ occupational therapist (PT/OT), as applicable, that do not exceed 10 percent of the total service are not subject to the payment reduction; while portions of a service furnished by the PTA/OTA independent of the therapist that exceeds 10 percent of the total service, or unit of service, must be reported with the CQ/CO modifier, alongside of the corresponding GP/GO therapy modifier.  Portions of services provided by the PTA/OTA together with the PT/OT are counted as services provided by the PT or OT. 

For CY 2022, CMS revised the de minimis policies and defined 2 exceptions when the de minimis standard is not applied:

  • In cases where there is one final 15-minute unit left to bill, the “8-minute rule” rule is applied when the PT/OT furnishes 8 or more minutes (the Medicare billing requirement for that final 15-minute service unit) – that final unit is billed without the CQ/CO modifier because the PT/OT provided enough minutes on their own (more than half) to report the service.
  • When there are two units of the same service remaining to be billed, and the PT/OT and the PTA/OTA each furnish between 9 and 14 minutes of a 15-minute timed service where the total time of therapy services furnished in combination by the PTA/OTA and PT/OT is at least 23 but no more than 28 minutes, one unit of the service is billed with the CQ/CO modifier (for the unit furnished by the PTA/OTA) and one unit is billed without it (for the unit furnished by the PT/OT)

 

Documentation Requirements

There are no additional documentation requirements for the CQ and CO modifiers. CMS previously ruled that “we would expect the documentation in the medical record to be sufficient to know whether a specific service was furnished independently by a therapist or a therapist assistant, or was furnished ‘in part’ by a therapist assistant, in sufficient detail to permit the determination of whether the 10 percent standard was exceeded.”

 Example #A:

PTA - 10 minutes of 97110

PT  –  5 minutes of 97110

Total = 15 minutes – qualifies to bill one 15-minute unit (8 minute to 22 minutes).

Bill as Follows:  Bill 1 unit of 97110 with the CQ modifier because the PTA provided more than 10 percent of the service in a case where the de minimis standard applies. 

Example #B

PTA – 5 minutes 97110

PT  ─ 30 minutes 97110

Total = 35 minutes – 2 units can be billed (23 minutes through 37 minutes). 

Bill as Follows Bill two (2) units of 97110 without the CQ modifier because the PT provided 2 full 15-minute units. 

Example #C:

PTA-22 minutes of 97110

PT – 23 minutes of 97110

Total = 45 minutes ─ qualifies to bill 3 15-minute units (38 minutes through 52 minutes).

Bill as Follows:  Bill 1 unit of 97110 with the CQ modifier because the PTA provided a full 15-minute unit, and bill 2 units of 97110 without the CQ modifier – 1 unit for the full 15-minute unit provided by the PT and 1 unit because the 8-minute rule is applied to the final unit.     

Example #D

PT – 12 minutes of 97110

PTA-14 minutes of 97110

PT – 20 minutes of 97140

Total = 46 minutes – qualifies to bill three units (38 minutes through 52 minutes)

Bill as Follows:  Bill 1 unit of 97140 without the CQ modifier because the PT provided a full 15-minute unit. Then, for the 2 remaining units of 97110:  bill 1 unit of 97110 with the CQ modifier and 1 unit of 97110 without the CQ modifier.

 

New CPT Codes 

Remote therapeutic monitoring

Data around indicators such as therapy/medication adherence, therapy/medication response, and pain level can be collected and billed under the new RTM codes. 

CPT# 98975

Descriptor: 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# 98976

Descriptor: 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# 98977

Descriptor: 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

 

CPT# 98980

Descriptor: Remote therapeutic monitoring treatment, 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#98981

Descriptor: Remote therapeutic monitoring treatment, 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

 

How often can the RTM codes be billed?

Code 98975 may be billed once per episode of care. An episode of care begins when the remote therapeutic monitoring service initiates and ends with the attainment of targeted treatment goals.

Codes 98976 and 98977 may be billed once per 30 days.

Code 98980 may be billed once per calendar month regardless of the number of therapeutic monitoring modalities performed in a given calendar month. Code 98981 may be billed once per calendar month for each additional 20 minutes completed within such month.

 

Can RTM data be self-reported by the patient?

RTM data can be self-reported by the patient, as well as digitally uploaded via the device. While RTM codes still require the device used to meet the FDA’s definition of a medical device, self-reported RTM data via a smartphone app or online platform classified as Software as a Medical Device (SaMD) may qualify for reimbursement, according to CMS. 

 

We cannot bill the normal PT/OT codes for telehealth after the end of the pandemic

As indicated in the proposed rule, CMS has reiterated that PTs, OTs, and SLPs will not be able to provide telehealth after the conclusion of the public health emergency (PHE).