So we do have an initial
reaction to the fee schedule,
which was published.
It will actually be finally
published at the end of August.
Sorry,
at the end of July in the Federal
Register.
But what CMS does and a
whole bunch of other agencies do
is they produce a
pre-publication copy to
give folks a little bit
more time to look at it.
They look very different in
terms of formatting and
that kind of stuff,
but it just gives us more
of an opportunity to really
dive in and try to understand it.
So that goes on display.
And what's also nice that
CMS did is because of the
importance of this regulation,
They also produced a whole
bunch of background materials,
other things explaining
what they're trying to
accomplish within the fee schedule.
So the top line is we're still bummed.
We're still frustrated
seeing red while you try to
get in the black with the
cuts in the fee schedule.
There is a statutorily
mandated 2.8 percent cut
that CMS had to implement
based on what Congress gave
them for an appropriation
and really an entitlement.
But the money just wasn't there.
in order for CMS to do
anything but create that cut.
So CMS is sort of in a box
and it's why it's so
important for folks to
engage in congressional
advocacy on the payment cut
as well as stuff with CMS
because Congress sets that rule, right?
There's a sort of,
the way that it works is
Congress produces the
skeleton and the regulatory
agencies produce the flesh, right?
And so this is an expression of that,
happens every year, and it's really,
really critical to know
what it's gonna do.
So overall,
2.8% cut across the board for
all specialties who use Part B.
So that's physicians, that's nurses,
that's a whole bunch of
other folks who are in the
healthcare profession
that's not hospitals.
But it is, you know, the caregivers,
I would argue.
And so very frustrating.
We'll push back against it, like I said,
with Congress.
And then hopefully,
just like last year and the
year before and the year before,
we'll be able to blunt that
cut and make sure that in the lame duck,
that there will be some
movement in terms of
limiting how bad it is.
There are, however,
a whole bunch of really
good things in this fee schedule.
And you might remember the
breaking news that we had a
little bit back that
predicted some of these things.
And we got very lucky or
just had very good advocacy.
APTA had very good advocacy
to get CMS to really take
our side of some of these
really in the weeds policy choices.
And one of them I'd like to
highlight actually was one
I'd mentioned that may have
seemed a little bit in the weeds.
There are 19 codes that are
often used by PTs that were
impacted by the multiple
procedure payment review.
And basically what happened
is we were successful,
APTA was successful at
getting CMS to recognize
that these physical
medicine and rehabilitation
codes were misvalued.
And so APTA produced a great
list for these 19 codes and
suggested what are known as
RVUs or relative value
units that are associated with the codes.
And even a smaller component of that,
the PE expense component of
what the RVUs become.
So the way it works is
there's RVUs associated with each code,
and then there's a couple
other modifiers that
that gets modified or
multiplied by what's called
the conversion factor.
And that gives you a dollar figure, right?
So the conversion factor,
that 2.8% cut looks like about $32.
But what's really nice is
some of the inputs for 16
of these 19 codes went up significantly.
So even with that 2.8% cut,
you're going to actually see
some increases in really
commonly used codes.
They're not going to be big,
and there were three that
actually are commonly used as well,
but one very commonly used
that went down in value.
But overall,
even though there's that 2.8 percent cut,
because some of the inputs
and what the RVUs will
become and then get
multiplied by the conversion factor,
you're actually going to see
a couple of cents increase.
That's not going to track with inflation,
but it is certainly better
than an almost 3% cut, which again,
I'm very hopeful we'll be
able to blunt through
congressional advocacy.
So really good news on those codes.
I'm not going to go through
each of them here.
This chart is on page 179 of
the pre-publication copy,
and it looks a little
misleading because it says
that there's the three columns.
One is the proposed RPE guidelines.
Then there's the ones that
the RUC produced,
the Relative Value Update
Committee and its
subcommittee that deals
with misvalued codes.
And then APTA proposed ones,
RVUs or PE inputs that were even higher.
And CMS explicitly states in
their regulation
we're going to take the middle road.
We're not going to go with
what we had in the past.
We're going to go with what
the RUC suggested.
And I think having the APTA
suggest even higher RV use
really made it easier for
them to be in the middle and say,
we'll go with the RUC.
So you always want to be
thinking in negotiation,
where's the fallback for
folks that probably won't
automatically take the high road,
as I would put it.
But bottom line,
what's going to happen
because of those misvalued
codes is many of the codes
that are used by PTs will
actually be paid marginally higher.
Now, again,
that's also why it's incredibly
important to do effective
congressional advocacy on
blunting the cut.
Because if we're able to blunt the cut,
those increases will
actually be even higher
because the bottom line
dollar figure that you get
paid for each of those codes,
misvalued codes,
will increase if we
decrease the overall
payment cut that others receive.
So that's really good news.
It's going to be a little counterintuitive,
I think,
for folks to see when 2025 rolls around.
And it's also not guaranteed.
Right.
What we need to do is in comments to CMS,
because this is the draft rule,
not the final rule,
we need to praise them and
thank them and say,
you're the best ever
because you implemented
these misvalued codes increases.
Now, we, of course, would want to say,
please take the APTA ones
in any future rulemaking.
But overall,
I would say that's a positive
and it's going to be a
little bit of a surprise, I think,
to folks.
they might actually see
increases very very small
but marginal increases and
perhaps not decreases even
with the 2.8 percent cut
which again we hope to
decrease so again in the
weeds but I think that's
really good news uh and and
I just can't uh thank apta
enough for the advocacy
they did to make that um to
make that uh uh that change
um but we've got to keep it
and that's why it's so
important to do advocacy
The KX modifier,
this is one of the
modifiers that is used by PTs very often.
That actually increased the
threshold for using that modifier,
increased to $2,410 for PTs
and speech language pathology services.
That represents a 3.6% increase.
So if you start doing a
whole bunch of services for someone,
that threshold when they
start looking and auditing
that individual's care
actually has increased to 3,000,
but it's sort of a gray
area or a possible review after 2410.
And again, that's for individuals.
PT services and speech
language pathology services combined.
Different for occupational therapy,
that's its own individual 2410.
But what's great is that
that's an increase of 3.6%.
They recognize that costs are going up,
especially for those really sick patients,
the PT,
or the folks who are frequent
flyers with PT, who get a lot of PT,
they are going to have the
opportunity to receive more PT,
which we of course think is
a good result as a result
of that threshold increase.
One other thing that I think
is just really great is the
breakthrough on PTA general supervision.
And as you may have known,
PTs were really required to
be on site for supervision
requirements under prior CMS rules.
What's really great is that
CMS has recognized that
they're going to be able to
extend care of PTAs by
having PTs be available to
provide direct oversight.
In the past, direct supervision,
the PT had to be physically
on site while services were delivered.
General supervision,
which is where we're going to go here,
is what the new rule will
be if we can keep it.
That requires only that the
PT be immediately accessible,
but not physically in the
office or patient's home with the PTA.
This is a one-two punch that
I'm not totally psyched about,
but I think it's such an
important pushback on the
15 percent PTA decrease in payment.
And I think this just makes
sense with the focus on
CMS's advocacy and health equity, right?
And health equity,
if you think about who
receives PTA services within the country,
within the real world,
not just within this fee
schedule craziness,
it's generally folks in
rural areas and underserved
communities in urban areas.
It's not these suburban
rings where folks are
really getting a lot of PTA
services or services provided by PTAs.
So if a PT is able to
oversee multiple PTAs as
opposed to having to be on site,
you're going to really see
some increases in access.
At least that's the hope.
And that's really good, right?
We're going to get more PT
services to more people.
The thing that stinks is
that that 15% decrease in
PTA payments is going to
impact that access.
So again,
I think it's sort of giving with
one hand and taking away with the other.
Still,
with the patient focus on allowing
general supervision,
it's an important step forward,
and we need to praise CMS
for listening to us.
That is also a result of
this dance that Congress does with CMS.
APTA and others have been
very supportive of a piece
of legislation that is bipartisan,
looks like it was on its
good way to passage, and CMS sort of beat
the Congress to the punch.
I still think it's important
that we advocate on that
legislation to sort of lock
in what CMS has to do.
This is really a regulation
which is underneath a statute.
We wanna change the statute too.
So it always stays this way
and that general
supervision gives away or
is allowed as opposed to
this direct supervision structure.
But this is the empower act.
And I think that progress in
moving that bill through
the congressional process
helped to justify CMS as saying, okay,
yeah, we can do this on our own anyway.
So why don't we go ahead and
at least do it, study what it does,
and then be able to provide
more information on it.
But good news in general
supervision versus direct supervision,
APTA, again, got a win there.
burdensome plan of care requirements.
It is so frustrating for PTs
to need to provide care
quickly for folks who, you know,
that's the highest quality
care is when it's provided
quickly after an injury,
or you just get the best outcomes, right?
When folks are able to get
into the PT quickly,
And in those instances,
sometimes you have to wait
on the plan of care being
signed off on by the referring clinician,
right?
Physicians, others,
sometimes they sit on those documents,
right?
And they don't sort of
prioritize signing those.
And then really the PT is on the hook.
They really don't have the
authority to provide care
until the plan of care is signed off on.
That is changing under this
new regulation if it becomes final.
And so we have to praise CMS for this.
There's a new rule on the
plan of care requirements.
And we're going to comment on this.
But basically,
the way it works is the
proposal would allow the
physician's signed order or
referral to demonstrate
initial certification of
the PT's plan of care.
And that's different than
the way it works now, right?
PTs must send their plan of
care to the referring physician
and secure a signature
within 30 days with a PT
bearing all the
responsibility of getting the signature.
Otherwise,
the PT has to choose between
stopping treatment or
proceeding with the risk of
not being paid by Medicare.
If you can't get that signature,
it's really on you whether
or not that care will be reimbursed.
And if you don't get the signature,
it doesn't get reimbursed.
So this basically provides a
cushion for PTs to be able
to provide that care.
Again, really strong for patient results.
Again,
there's such good evidence to show
that if folks get PT quickly,
they do have better outcomes.
So this is a thing that's
hopefully going to decrease
the risk that PTs have to
take providing care to
folks when the plan of care
is not signed off on.
I just think it's critical
that that happen,
and we really need to praise CMS in that.
And then the final thing I'd mention is,
let's see,
I think I may have actually
covered everything.
Really,
the conversion factor is going to
be the main focus of our
work and making sure that
the conversion factor
continues to be decreased.
And then we'll see that
increase from the misvalued
codes analysis hopefully be
even more effective.
And so I think 2025
even with these continued cuts,
might be a better year than
2024 in terms of Medicare payment,
as well as some of the
administrative burden that
folks have to deal with in
their practices.
So again, conversion factor cut.
We also have that
information on the cap for
the KX modifier.
We're also very happy with
the breakthrough on PTA
general supervision.
and then the plan of care
requirements as well as the
misvalued codes.
There's a lot to be happy
about in this fee schedule,
but we have to lock it in
and make it final and
certainly not decrease the
advocacy that folks are
doing on Capitol Hill so
effectively because that is
spurring CMS to make some
of these changes that they
have the authority on their own to make.
We need to get Congress to
get out of the way and
change some of those rules
that CMS is locked into in
terms of payment.
But in the things that CMS
had the authority to change
on their own under the statute,
I think they've done a great job.
So kind of a little
different than in many
instances where we are even
more disappointed by the fee schedule.
The main thing that stinks
is the payment cuts, but
uh again I think I think we
might see some um relief
from that uh this year uh
if we do our advocacy on
capitol right uh and we'll
hopefully be able to um to
see some uh better working
systems uh and more money
on the table for for pts to
run their practices hire
new folks get more ptas uh
help some of those students
uh pay off their loans by
offering them perhaps a
little bit more and
generally increasing access
for PT services throughout the country.
So good on you CMS for
listening to all that APTA advocacy.
We have to do our job in
Congress and also on the
regulatory comments to make
sure so many of these good
things remain in the final rule.
So good news in many instances,
but we've got to do our
work to push back on how
much money Congress is giving to CMS
to pay for Medicare Part B's payments.