CMS proposes regulations on assistant use and payment – Comment now!

Medicare has released their 2020 Fee Schedule proposed rule, including regulations regarding the documentation and billing for PTAs and OTAs. As you may recall from our webinars earlier this year, beginning on 1/1/2020, therapists will be required to use CQ and CO modifiers to show when services are furnished “in whole or in part” by a PTA or OTA. Beginning 1/1/2022, payment for those services will be reimbursed at 85% of the applicable Part B payment. This year’s proposed rule defines “in part” to mean when an assistant furnishes a portion of a service either concurrently with, or separately from, the part furnished by the therapist, such that the minutes for that portion of a service furnished by the assistant exceed 10% of the total minutes for that service.

CMS supplied scenarios to illustrate the reimbursement impact of a variety of situations where a therapist and assistant both provide care to a patient. For example, if a therapist spent the entire 60-minute service providing direct care to a patient, but during that session they required the side-by-side assistance of a assistant for 7 minutes, the entire hour of service would be subject to the 15% payment reduction. Furthermore, when a therapist is furnishing care and requires the help of an assistant as a “second set of hands” for safety or effectiveness purposes, then the therapist’s time is ignored for payment purposes, and this treatment time is instead attributed to the assistant and is subject to the 15% payment adjustment.

PTPN opposes this methodology of assigning modifiers when team-based care is delivered. This policy is inherently complex, a significant overreach of CMS’s statutory authority, and it is not in line with congressional intent. These changes could result in significant underpayments for therapy services beginning in 2022, which could thereby severely restrict patient access.

The policy fails to put the needs of the patient first, while ignoring and undermining the clinical reason for team-based care, by effectively imposing a financial penalty on those providers who work with assistants. This may result in PTAs/OTAs losing their jobs because the role of a therapy assistant would no longer be economically feasible for certain practice types, sizes, and locations.

This approach suggests that CMS seeks to reduce reimbursement not only for the assistant’s services, but also for the services performed by the therapist. Under Medicare policy, the therapist is responsible for the patient’s plan of care, and the assistant furnishes services under the direction and supervision of the therapist. When a therapist and assistant are jointly furnishing services to a patient at the same time, and the therapist is fully engaged in the service during that time, the service during that time period should be allocated to the therapist.

PTPN believes that the 10% of total minutes standard for the assignment of the CQ/CO modifiers should only be applied to services furnished in whole or in part independently by the assistant. Therefore, CMS must instead define “in whole or in part” to mean skilled therapy services furnished by an assistant under the supervision of a therapist, but independent of any time the therapist is furnishing the service. Services furnished jointly by a therapist and assistant team, where the assistant is supplementing the therapist’s services, should be considered therapist services, and should not be attributed to the assistant’s time in the determination of the CQ/CO modifier. If both a therapist and assistant are furnishing care to a patient, it is evident that it requires two professionals and is a highly skilled procedure or is required for safety reasons. There would seem to be no justification to diminish reimbursement for these services.

Further, the documentation requirements are extremely burdensome! The minute counting alone is unrealistic at best. Who is going to be standing by with a stopwatch counting 1.5 minutes for a 15 minute procedure to arrive at 10%? Who can estimate the difference between 1 and 2 minutes accurately? CMS also proposes that, regardless of whether a PTA/OTA is employed by a clinic, the treatment notes must explain why the CQ/CO modifier was or was not applied for each service furnished that day. What about clinics that don’t employ assistants? This could serve as another justification for denial of payment by a reviewer for a medical record that would otherwise be acceptable. At the very minimum, CMS should exempt offices that do not utilize assistants, and should not require any justification for not using an assistant.

PTPN has sent detailed comments to CMS on this and other fee schedule topics. If you would like a copy of PTPN’s comments, email Jana Merhej at jmerhej@ptpn.com. If you are concerned about this issue, we strongly suggest you submit comments on this CY 2020 Physician Fee Schedule proposed rule by going to www.regulations.gov/comment?D=CMS-2019-0111-0092. It’s easy! You can either comment directly in the comment box or upload a letter under “Upload Files.” You can add your own experience with assistants, modify our comments here, and/or create your own.

The more people they hear from, the more impact it will have. The deadline for comments is 9/27.

Together we can make a difference.