Words Matter: CMS Proposes How to Identify OTA-Provided Services
On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule proposed rule which includes proposals for the Quality Payment Program, all of which govern Medicare Part B payment and quality reporting policies. See AOTA’s summary.
While several important Medicare Part B issues were addressed, of critical importance to the occupational therapy community are the proposals related to implementing requirements in the Bipartisan Budget Act of 2018 (BBA2018) to use a new modifier for OTA-provided services in 2020, and to reduce payments for OTA-provided services by 15% in 2022, meaning that OTAs will be paid at 85% of the applicable Part B payment amount for the service.
The proposed rule gives AOTA insight into CMS’ interpretation of key concepts in the law, including the interpretation of which services are furnished “in whole or in part” by OTAs. Defining “in whole or in part” will be a critical aspect of CMS’ implementation of the OTA payment differential.
CMS is suggesting that a modifier be used on the Medicare claim form for any Part B setting (outpatient hospitals, private practices, skilled nursing facilities, home health agencies, CORFs, and rehabilitation agencies) whenever a service is provided “in whole or in part” by an OTA so that these services’ payments may be reduced. In the proposed rule, CMS suggests that defining “in whole or in part” rests on different criteria for treatments and for evaluations.
For treatments, CMS says they will apply the cut to services “when a PTA or OTA is involved in providing some or all of the therapeutic portions of an outpatient therapy service.” They go on to say this means “any minute of the outpatient therapy service that is therapeutic in nature” and when the PTA or OTA is “acting as an extension of the therapist.” CMS is very clear that this does not include administrative tasks like greeting and gowning or scheduling the next appointment, but rather focuses on the therapeutic intervention.
While CMS is clearly continuing to recognize OTAs as providers of occupational therapy, the description creates many questions. AOTA is analyzing this description carefully because it is not clear what CMS means by an outpatient therapy “service.” For instance, if a “service” is one 45-minute session in which 3 units of any code are provided, if the OTA provides 1 unit of self-care and the OT provides 2 units of cognitive treatment to the same patient, are all three units reduced or only the unit provided by the OTA? What if the OTA and OT are working together directly and collaborating on treating a single patient as they provide 3 units of treatment? Are all these reduced? AOTA wants to hear from members about which treatment model predominates in Medicare Part B practice settings.
AOTA will be arguing that clarifying the billing parameters related to OTA and OT services in treatment sessions must be paramount. AOTA is also concerned about how group therapy will be considered, especially when an OT and OTA are jointly facilitating a group.
CMS also speaks to the involvement of an OTA in providing an evaluation. CMS’ current policy is clear that the evaluative process is the responsibility of the therapist and that OTAs and PTAs are not permitted to independently “wholly” furnish evaluations and re-evaluations. However, CMS goes further in the proposed rule to say that “to the extent that they (OTA or PTA) furnish “part of” an evaluative service the payment reduction should be applied.” This is contrary to current AOTA practice guidance supporting OTA contributions to an evaluation.
AOTA wants to know your experience of current practice in Part B settings with regard to the OTA’s contribution to the evaluation. CMS is emphasizing that the clinical judgment and decision making used in furnishing an evaluation relates to activities of the OT. CMS is clear that the therapy plan can only be established by a therapist, physician, or non-physician provider (e.g., nurse practitioner).
AOTA has provided the full discussion of the OTA/PTA Modifier section of the Medicare proposed rule, so you may read the CMS language directly.
Discussion threads have been initiated on CommunOT, including one by Melissa Tilton, the AOTA’s Board of Directors OTA member, in which members can offer their perspective and information on current practice.
AOTA is seeking a Congressional study to determine possible effects of these proposals on access to occupational therapy services. AOTA is also continuing to gather information from OT practitioners billing under Part B to identify current practices with regard to evaluation contribution, supervision, and billing. See AOTA’s FAQs on the underlying legislation and learn more about what AOTA is doing to respond to this issue.
AOTA will continue to examine current practice and gather information from members to determine how these proposals might affect current care settings. Participate in the discussions on CommunOT or email regulatory@aota.org to share your experience or opinion.