Four Ways Medicare Final Rules Affect OT: Coding Rates, Therapy Cap, & More


The Centers for Medicare & Medicaid Services (CMS) released final rules for the 2018 Medicare physician fee schedule (PFS) and the Quality Payment Program (QPP), which apply to Medicare Part B services. We’ve summarized four important big picture changes that you need to know about.

OT Code Reimbursement Changes

Several codes for occupational therapy interventions will get an increase in reimbursement under the 2018 Medicare Fee Schedule. Increases were given to therapeutic activities (97530), orthotics management and training (97760), and sensory integrative techniques (97533), among others. The increases are based on recommendations from an American Medical Association Health Care Professional review panel (AOTA is an active participant in that panel) and follow the professional survey AOTA conducted last winter in which hundreds of occupational therapy practitioners provided data. Some codes related to occupational therapy may have reimbursement decreases, including most of the modality codes. AOTA is still reviewing the final rule and calculating other payment effects.

Therapy Cap Increased and Medicare Diabetes Prevention Program Expanded

The therapy cap amount will increase from $1,980 to $2,010 in 2018 (go to the CMS announcement). AOTA’s efforts to repeal the therapy cap are progressing in Congress with the announcement of a bipartisan agreement in both the House and Senate on a policy framework to permanently repeal the cap. Read more about the framework.

The final rule also implements the Medicare Diabetes Prevention Program (MDPP) expanded model starting in 2018. The final rule includes additional policies necessary for suppliers to begin furnishing MDPP services nationally in 2018, including the MDPP payment structure, as well as additional enrollment requirements and compliance standards.

For more information: CMS issued a fact sheet on the Fee Schedule final rule.

We’re Keeping an Eye On These Quality Changes

CMS recently launched the “Patients Over Paperwork” Initiative, which seeks to streamline regulations with a stated goal to “reduce unnecessary burden, increase efficiencies, and improve the beneficiary experience. This effort emphasizes a commitment to removing regulatory obstacles that get in the way of providers spending time with patients.” CMS states that they are working several concepts of this initiative into the Quality Payment Program, which could impact occupational therapy practitioners. Currently occupational therapy practitioners are not yet eligible for participation in the related Merit-Based Incentive Payment System (MIPS), but can voluntarily report under MIPS.

CMS finalized a policy to exclude individual MIPS-eligible clinicians or groups with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries. This policy could exclude a large percentage of occupational therapy practices from being required to report to Medicare under MIPS if therapists become eligible for MIPS in CY2019, as is anticipated.

How Will OT Operate in an Alternative Payment Model (APM) World?

CMS continues to refine the APM track of MACRA to make it a more attractive option for eligible clinicians and increase overall APM and Advanced APM participation. In the final rule, CMS has provided details on how it intends to incentivize participating clinicians and reduce complexity of the program by way of creating additional flexibilities and pathways for providers to be successful under this track. AOTA continues to closely monitor bundled payment models, like the Comprehensive Care for Joint Replacement, to assess the impact on the profession. CMS has issued a fact sheet and an Executive Summary on the QPP final rule.

AOTA Regulatory Affairs staff is continuing to review each of these final rules more in depth and will provide an analysis on each rule soon.