Proposed rules almost always become final rules. On November 2, 2021, the Centers for Medicare & Medicaid Services (after threatening for four years) finalized the 15% payment reduction for outpatient services delivered by physical and occupational therapy assistants in 2022.
There are lobbyists working as you’re reading this to defray the losses. You can read the 1700 pages of the rule yourself, or I can break it down for you.
In 2010, the Multiple Procedure Payment Reduction (MPPR) for therapists was implemented and dropped the payment for some CPT codes by 25% (of part of the fee) when delivered simultaneously with other services. This extended to all venues and increased to 50% in 2013. The implementation of this rule was the first time specific codes were devalued when delivered by therapists. Until now.
When Congress repealed the therapy cap in 2018, they threatened the assistant differential to preserve budget neutrality. The 2019 Final Rule determined the payment differential that we’ll see in 2022.
Most skilled nursing facilities either employ their own physical therapists, occupational therapists and licensed assistants, or contract those services. Because therapists carry more responsibility and require a higher education level, they are paid more than the assistants.
The hourly rate for a therapist can be 40-50% more than for an assistant. Because of this, most of us employ assistants and therapists at a 3:1 ratio. This means the therapists conduct the evaluations, establish the plans of care, cosign documentation, re-evaluate and discharge patients as appropriate. The assistants carry out the plan of care and consult with their clinical supervisor. Some of us don’t even have therapists full-time; they come in when evaluations or discharges are needed.
Under this new final rule, all Part B treatments conducted by assistants will be reimbursed at 15% less than the therapist rate. This only pertains to Part B (outpatients, non-skilled inpatients, Part B home care), and not the skilled population. This also pertains to services provided in full OR IN PART by a PTA or OTA.
There’s actually a formula to determine what “in part” means and also determines that there are times when the assistant’s treatment time can be disregarded. The new CQ and CO modifiers have to be attached to those services. Since the 15% differential applies only to the allowed charges that Medicare Part B pays (80%), the differential is actually 12%.
I know, I know. Nothing is easy. And there is more analysis to come.
How does this impact your practice?
Does it make sense for your SNF to eliminate assistants because the reimbursement for their Part B services will decrease? Is your ability to procure therapists and replace assistants impacted by shortages? Keeping in mind that the 40-50% more you will pay a therapist to mitigate the 12% decrease in Part B is severely out-of-whack, can your facility absorb the drop and continue as usual? Do you need to renegotiate your contracts to pay less when an assistant delivers the Part B service?
My advice is to keep going. Your standard procedure, the way you currently staff and the way your rehab staff is working is the path to take. You will see a minor hit in your outpatient revenue, but analyzing your staffing to make the best use of the modifiers and maximize the benefit to your patients and residents is always the right way to go. If we know anything about long-term care, we know we have to adapt.
As I tell my staff: Always do the right thing for the patients. The money will follow.
Jean Wendland Porter, PT, CCI, WCC, CKTP, CDP, TWD is the regional director of therapy operations at Diversified Health Partners in Ohio.
The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.
