Medicare Compliance & Reimbursement

Find out what the rehab industry can expect in 2005.

Sometimes CMS gives with one hand while taking away with the other. That's what the agency has done in the final Physician Fee Schedule for 2005 for therapy - but both actions are to therapists' benefit.

The final 2005 physician fee schedule, published in the Nov. 15 Federal Register, reads almost exactly like the proposed regulation where therapy interests are concerned, which is a big relief to therapists. "The rehab industry negotiated well, and they got what they wanted," notes consultant Fran Fowler with Fowler Healthcare Affiliates in Atlanta.

The two major issues on the table: who can receive reimbursement for therapy provided incident to a physician's services, and the degree of supervision Medicare requires for physical therapist assistants and certified occupational therapy assistants working in private practices.

Prepare for Tighter Incident-to Restrictions

Effective March 1, CMS will regulate more strictly who can be paid for therapy services provided incident to a physician's services. Specifically, the rule says Medicare will not pay for PT, OT or SLP services provided by "individuals who do not meet the existing qualification and training standards for therapists (with the exception of licensure)."

That means anyone providing therapy in a physician practice must have graduated from a therapy curriculum approved by the American Physical Therapy Association, the American Medical Association's Committee on Allied Health Education and Accreditation, or the AMA/APTA's Council on Medical Education.

Caveat: These training requirements do not apply to physician assistants, nurse practitioners or clinical nurse specialists working in states that allow these non-physician practitioners to provide therapy services.
 
The restriction applies to any therapy service included on CMS' list of "always therapy" services, the rule states. These services are those for which the code requires a modifier to describe whether the service falls under PT, OT or SLP.

This section of the rule doesn't take effect until March 1, rather than Jan. 1, but that doesn't come as a surprise to industry leaders. "There was a feeling [CMS] might need to delay implementation," says Dave Mason, APTA's vice president of government affairs. "We don't have any problem with that [schedule]," Mason tells MLR. "Better to do it right than try to rush into it just to meet the Jan. 1 deadline."
 
"It appears that there may be a large number of people providing therapy without being properly qualified to do so," according to Leslie Stein Lloyd, regulatory council for the American Occupational Therapy Association's reimbursement and regulatory policy department. That means many physician practices will need the extra time to restructure, she notes.

This final rule comes as bad news to many providers who are unable to provide therapy services to Medicare beneficiaries in physician practices, such as certified athletic trainers. "With this action, CMS has assured that physical therapists will have a virtual monopoly on the delivery of therapy services to Medicare beneficiaries, both inside and outside the physician's office," says Chuck Kimmel, president of the National Athletic Trainers' Association, in the association's written response to the rule.

Athletic trainers agree with therapists that untrained and unqualified people shouldn't provide rehab services, but argue that CATs are among those properly trained and qualified, says Marjorie Albohm with Orthopaedics Indianapolis. "Medicare patients deserve to have a choice of qualified providers ... Competition improves product," she says. The health care landscape is changing, Albohm notes, and CMS should "give emerging professionals a fair chance," she posits.

Non-therapists are allowed to bill incident to for non-therapy services they are qualified to provide, CMS makes clear. "For example, a physician may apply a surface neurostimulator (CPT 64550) as an isolated service, outside of a therapy plan of care and appropriately bill the code without a therapy modifier," the rule offers. In this case, the physician may supervise non-therapist "auxiliary personnel" to perform that service - if that person is qualified to provide it - because the service rendered is not therapy.

CMS Loosens Supervision Requirements

While therapists benefit from CMS tightening its grip on one hand, they also benefit from loosened requirements on the other. Under the final rule, PTAs and COTAs in private practice settings can provide services under "direct supervision," rather than the more stringent "personal supervision" requirement.

"Personal supervision" means the supervising PT or OT must be in the same room with the assistant providing services. "Direct supervision" only requires the PT or OT to be "in the office suite."
 
"We've argued for that change for a while, and we were delighted to see it in the final rule," Mason cheers. Medicare's personal supervision requirement for PTAs and COTAs in private practice went far beyond any state law, Lloyd points out, and OTs have long argued that the requirement is unnecessary.
 
"We're glad they finally agreed with us. We scratched our heads for a long time about that one," she quips.

Editor's Note: The 2005 physician Fee Schedule is available at www.cms.hhs.gov/regulations/pfs/2005/1429fc/master_background_1429-fc.pdf, and the therapy provisions are on pp. 553-582.