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July 2017 FAL Update
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July 2017 FAL Update

Bear with me, our APTA Federal Grassroots Liaison changed so we did not have a typical June call – making this month a doozy….

 Regulatory Update

Quality Payment Program Proposed Rule

- The proposed rule came out in late June.

- APTA was hopeful that CMS would notify PTs of our participation in 2019. They did not, so we’ll have to wait until next year.

- If you have very specific concerns about the program, feel free to reach out to the APTA at: about what could be coming.

- Comments on the rule are due August 21.


Physician Fee Schedule Proposed Rule

- On July 13, 2018, CMS released the proposed CY 2018 Medicare Physician Fee Schedule.

- Of the 19 CPT codes identified by CMS as potentially misvalued, CMS is proposing increases in several of the codes’ work RVUs.

- Specifically, CMS proposes the following:

-Accept the HCPAC’s recommended work RVUs for CPT codes: 97012, 97016, 97018, 97022, 97032, 97033, 97533, 97034, 97035, 97110, 97112, 97113, 97116, 97140, 97530, 97533, 97535, 97537, 97542, and G0283 (97014).



- 97012: 0.25 (no change)

- 97016: 0.18 (no change)

- 97018: 0.06 (no change)

- 97022: 0.17 (no change)

- 97032: 0.25 (no change)

- 97033: 0.26 (no change)

- 97034: 0.21 (no change)

- 97035: 0.21 (no change)

- 97110: 0.45 (no change)

- 97112: 0.50 (increase from 0.45)

- 97113: 0.48 (increase from 0.44)

- 97116: 0.45 (increase from 0.40)

- 97140: 0.43 (no change)

- 97530: 0.44 (no change)

- 97533: 0.48 (increase from 0.44)

- 97535: 0.45 (no change)

- 97537: 0.48 (increase from 0.45)

- 97542: 0.48 (increase from 0.45)

- G0283: 0.18 (no change)


- Keep the existing CY 2017 practice expense inputs for the 19 codes.

- Keep the current values for the supervised modality services reported with CPT codes 97012, 97016, 97018, and 97022, and HCPCS code G0283 (97014) and not accept the HCPAC’s proposed values.

-For the management and/or training of patients with orthotics and/or prosthetics, CMS proposes the HCPAC recommended work RVU of 0.50 for CPT code 97760 (increase from 0.45), a work RVU of 0.50 for CPT code 97761 (increase from 0.45), and a work RVU of 0.48 for CPT code 977X1 (NEW CODE).

- CMS proposes to maintain the current PE inputs for CPT codes 97760, 97761, and 977X1.

- Note: CPT codes 97760 and 97761 were previously used to report both the initial and subsequent encounters. For CY 2018, CPT codes 97760 and 97761 are intended to be reported only for the initial encounter, and CPT code 977X1 is intended to be reported for all other orthotic and/or prosthetic services for an established patient that occur on a “subsequent encounter” or a different date of service from that of the initial encounter service

-Note: In 2017, the eval codes saw a slight increase in practice expense as a result of the RUC’s recommendations and varied based on geography. We should expect to see small increases in 2018 as well. So that means, in a 2 year period, we’re seeing an increase in payment for the services we provide

-APTA is drafting supportive comments on the proposed code values. Comments are due September 11th.

- You can get involved by submitting a letter of support for CMS’s proposals. The template letter will be available next week.


SNF Advance Notice of Proposed Rulemaking:

- Comments on the SNF ANPRM are due August 25th.

- Overview of CMS’s Proposal:

- CMS is considering revising the SNF PPS payment methodology to make payments more aligned with patient characteristics.

- Currently, payments to SNFs are primarily based on the amount of therapy provided to the patient, regardless of patient characteristics. The RUG-IV classifies each resident into a single RUG, with a single payment for all services. Moreover, each RUG is paid at a constant per diem rate, regardless of how many days a resident is classified into that particular RUG.

- By contrast, the RCS-I-case-mix-classification system would classify each resident into four components (PT/OT; SLP; Nursing; Non-Therapy Ancillary (NTA) Services) and provide a single payment based on these classifications. The new system removes therapy minutes as a determinant of payment and creates a new model based on patient characteristics.

- For PT/OT patients, patients are sorted by the clinical reasons for the SNF stay, cognitive function, and ADL score based on transfers, toileting, and eating. After identification of the variables for predicting the PT/OT costs, the patient is placed in one of thirty groups – each group matches up to one clinical category, one function score range, and one cognitive impairment level.

- The payment for each component would be calculated by multiplying the case-mix index for the patient’s group by the component federal base payment rate, and then by the specific day in the variable per diem adjustment schedule. These payments would then be added together, along with the non-case-mix component payment rate, to create a resident’s total SNF PPS per diem rate under RCS-I. PT/OT also would be multiplied by an adjustment factor.

- CMS believes that because the payment system is based on specific resident characteristics predictive of resource use for each component, payments would be better aligned with resident need.

- To review the SNF Advance Notice of Proposed Rulemaking (Pre-Proposed rule), please visit:



Hospital Outpatient PPS proposed rule:

- Proposals include:

- CMS proposes to update OPPS rates by 1.75 percent.

- CMS is proposing to reinstate the non-enforcement of direct supervision enforcement instructions for outpatient therapeutic services for CAHs and small rural hospitals having 100 or fewer beds for CYs 2018 and 2019

- CMS proposes to remove total knee arthroplasty from the IPO list, as well as whether partial and total hip arthroplasty should also be removed from the IPO list. (The Medicare inpatient-only (IPO) list includes procedures that are only paid under the Hospital Inpatient Prospective Payment System.)

- Comments are due September 11th.


Home Health

- CMS finalized the delay of the effective date of the CoPs to January 2018.

- HH PPS for CY 2018:

- CMS projects that Medicare payments to HHAs in CY 2018 would be reduced by 0.4 percent, or $80 million, based on the proposed policies.

- Sunset of the Rural Add-on Provision: Section 210 of the MACRA extended the rural add-on, which is an increase of 3 percent of the payment amount otherwise made for home health services furnished in a rural area, to episodes and visits ending before January 1, 2018. Therefore, for episodes and visits that end on or after January 1, 2018, a rural add-on payment will not apply.

- Home Health Grouping Model (HHGM): This rule proposes case-mix methodology refinements, including a change in the unit of payment from 60-day episodes of care to 30-day periods of care, to be implemented for 30-day periods of care beginning on or after January 1, 2019. CMS is not proposing a change to the split percentage payment approach in conjunction with proposing to change the unit of payment from a 60-day episode to a 30-day period of care; however, CMS is soliciting comments on the phase-out of the split percentage payment approach in the future.

- HHGM relies more heavily on clinical characteristics and other patient information to place 30-day periods of care into meaningful payment categories. The HHGM also eliminates therapy service use thresholds that are currently used to case-mix adjust payments under the HH PPS.

- The proposed HHGM includes changes to the episode timing categories, the addition of an admission source category, the creation of six clinical groups used to categorize 30-day periods of care based on the patient’s primary reason for home health care, revised functional levels and corresponding OASIS items, the addition of a comorbidity adjustment, and a proposed change in the Low-Utilization Payment Adjustment (LUPA) threshold. The LUPA add-on policy, the partial payment adjustment policy, and the methodology used to calculate payments for high-cost outliers would also be revised to be consistent with the proposed 30-day period of care.

- Comments are due September 25th.


Orthotics & Prosthetics Proposed Rule

-APTA met with CMS staff a couple weeks ago, during which time ATPA learned that they are still reviewing comments and if they end up finalizing it, it will take close to the 3 years they are allotted, before they would be required to start all over. The final rule, if finalized, could potentially be very different from what was proposed.


Congressional Update

-On Tuesday, July 24th, the Senate voted 51-50 to have 20 hours of floor debate on health care reform bills, specifically the Better Care Reconciliation Act (BCRA). Floor debate opened that

evening and a vote on the BCRA was held; BCRA was voted down 57-43.

-On Wednesday, July 26th, debate continued all day and into the evening with numerous amendments, motions, and the clean ACA repeal bill failed 55-45 that afternoon. (There are roughly 9 hours of debate left for the Senate to get a vote on a “skinny repeal” which would get rid of the individual mandate and repeal the medical device tax. This bill has yet to be drafted, but, if one is cobbled together and passes the Senate, the House and Senate would convene for a committee conference to get to an agreement for a bill that would head to the President’s desk.

If there is no bill passed during the 20 hours of debate, the Senate will go into a vote-o-rama. If this happens, any Senator from either party can offer as many amendments as they would like and all amendments would be voted on without any debate. There is a chance that Republican Senators will push a cobbled together “skinny repeal” during the voting in order to get some repeals accomplished.)(This was taking place during the call – we all know how it ended – Failed to pass 49-51)


APTA did release a statement opposing the BCRA because of the cuts to Essential Health Benefits (EHBs).


Therapy Cap Update

APTA Chief Executive Officer Justin Moore, PT, DPT, was offered an opportunity to testify on repeal of the Medicare therapy cap before a House of Representatives subcommittee on July 20. He cut right to chase. Moore made the case to the House Energy and Commerce Committee's health subcommittee that now is the time to do away with the yearly ritual of quick-fix exceptions to the $1,980 combined limit on physical therapy and speech language pathology services and the $1,980 limit on occupational therapy. The effort to end the therapy cap marks the 17th attempt to move away from what originally was intended to be a temporary provision adopted as part of the 1997 Balanced Budget Act. Support for ending the cap reached its highest level yet in 2015, when repeal efforts were backed by 238 cosponsors in the House but came up 2 votes short in the Senate. The vote was for an amendment to legislative package that ended the flawed "sustainable growth rate" policy regularly requiring damaging payment cuts, avoided only by nearly annual ad-hoc "doc fix" legislation.

Moore spoke on behalf of APTA, the American Speech-Language Hearing Association, and the American Occupational Therapy Association, which have worked together for years to end the therapy cap. He told lawmakers that the coalition advocates that any therapy cap repeal plan be based on 3 basic principles: ensuring patient access without unnecessary delays, establishing a targeted oversight system that does not result in interruptions in care, and creating better alignment with value and performance-based models of care. For its part, the House subcommittee is reportedly supportive of repeal, with subcommittee Chair Michael Burgess (R-TX) saying he hopes to avoid enacting another therapy cap exceptions process. "Much like the sustainable growth rate formula, we have a policy inherent to the therapy cap that no one supports," Burgess told the subcommittee.

More information – including video dispatches on the hearing – can be found at:



On July 14th, the House of Representatives passed the FY18 National Defense Authorization Act (NDAA). APTA has been working with several Congressional offices and the Armed Services committees to include language that would compel TRICARE to recognize physical therapist assistants and occupational therapy assistants. Report language was drafted and passed as part of an en-bloc package of amendments and added to NDAA when it was in the full committee in June. The language directs the Secretary of Defense to submit a report to the committee outlining the process used by the departments to include para health professionals as healthcare providers in the military health system by April 1, 2018. This review will look at the feasibility of incorporating PTAs, OTAs, and other para health professionals. This move is an important step forward that APTA hopes will ultimately lead to coverage of PTAs under Tricare.

Initially, Chairman McCain’s absence looked like it would postpone the legislation until September, but with his return last week the Senate will likely move forward soon on its version of NDAA. APTA is working with the Personnel committee members to include language as well.  APTA has received word that the issue could also be discussed when the House and Senate come together to conference the legislation. In every meeting, even with Chairs of Committees, APTA has received a positive response.


Summer Advocacy – Targeted Districts

Again, I am looking for anyone interested in hosting a practice visit for Senator Thune, Senator Rounds or Representative Noem.  I know this is somewhat last minute – however, the Senate moved back their summer Recess until after the 2nd week of August through mid -September, so I do believe we would be able to get something scheduled. If you are curious about doing this or want more information before committing feel free to contact me and I will discuss it with you – with no obligation to host the visit.


Telehealth and the CONNECT for Health Act

APT is currently looking for a Private Practice or an individual that participates in telehealth and would be willing to host a Member of Congress to show them what role telehealth plays in your practice and why it is valuable to you, your patients, and others around the country. Please let me know if you are willing and able to host a Member of Congress so that we can develop more knowledge around telehealth usage, the need for it in rural areas, and the importance that CONNECT for Health Act legislation would have on patients across the nation.


Thanks for hanging in there…


John Rounds, PT, DPT


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