We are over a month into 2022 and have already billed the first month of the 15% reduction in therapy reimbursement for our Medicare patients.
You’ll recall that Jan. 1, 2022, was the day that Medicare Part B started paying only 85% of the Fee Schedule if the service was provided by a Physical or Occupational Therapy Assistant. That seemingly arbitrary differential caused many providers to alter their service delivery.
This drop in reimbursement was threatened in 2018 when the Part B therapy cap was repealed. The federal government giveth, and they taketh away. The CQ and CO modifiers are now part of our billing approach, to be used when an assistant delivers a portion of the treatment. Some of us have developed strategies to “game the system.”
We may be funneling the Part B patients to therapists, limiting the therapy assistants’ time and contribution, and because of the limited availability of therapists, limiting the amount of therapy delivered on the basis of payer. Changing delivery of healthcare on the basis of payer is wrong in every scenario.
PTAs and OTAs play a crucial role on the therapy team and help bridge the gap in access to care. So what now?
We know that Medicare Part B pays 80% of the fee schedule, so the decrease in actual reimbursement is only 12%, which is still a lot. We know that the differential only impacts us when the PTA or OTA delivers more than 10% of a service, which means that we’re playing around with our billing to maximize it.
We also know that the final rule says that when a PT or OT provides “enough minutes of the service on their own to bill for the last unit of a timed service,” you can disregard the PTA and OTA time and not apply the modifier. These are some hoops to jump through.
Here’s what’s been suggested to determine the percentage of therapy time:
Method #1. Divide the number of minutes of care provided by the PTA/OTA by the total minutes of care provided, then multiply by 100. That gives you the percentage of time of care provided by the PTA/OTA. You are to round to the nearest whole number. CMS says anything equal to or greater than 11% requires application of the modifier.
Method #2. Simply divide the total time of care provided to the patient by 10 (round to the next whole integer) and add 1 minute to set the minimal time requirement. So if the treatment was 60 minutes total, then 10% is 6 min + 1 is 7 minutes. If the PTA/OTA care was 7 minutes or more, then the CQ/CO modifiers are added to those line items.
Yikes.
If your SNF has a therapy contractor, check your bill. You may not be seeing the modifiers, and you may not be seeing the decrease. Examine the first few bills of the new year to ensure that you’re not overpaying your therapy company. You may also need to re-assess your contract.
In-house therapy has advantages in this system, but also disadvantages. While in-house therapy affords the ability to ensure maximum outcomes for the residents, it also incurs expense in terms of benefits, workers’ compensation, etc. When you consider the therapist-to-assistant ratio in your building, keeping in mind that therapists are about 35% more expensive than assistants, hiring more therapists to avoid the 12% decrease may not be the answer. Also, consider that the 15% differential only applies to Part B therapy, which is generally only 10-20% of a SNF’s caseload.
Check your contracts and your bills. Make sure that the CQ and CO modifiers are applied appropriately. Don’t drop your assistants in favor of therapists, especially in the current market. Do what’s best for your residents, while ensuring correct billing and maximizing outcomes.
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.
