The Medicare Physician Fee Schedule (MPFS) 2020 Final rule resulted in many changes impacting ‘outpatient’ therapy.

The “Assistant Differential”

Beginning 1/1/2020, a modifier must be applied to all billing claims (outpatient settings) where more than 10% of the service is provided by an assistant (PTA or COTA). This is so that Centers for Medicare and Medicaid Services (CMS) can collect data on the volume of services provided by PTAs and COTA’s in preparation for the 15% reduction in payment scheduled to occur in 2022. (Casamba will automatically apply this modifier to claims). If this law remains in place all services provided by PTA’s and COTA’s will be paid at 85% of the Medicare Physician Fee Schedule rate vs the 100% paid today beginning in 2022.

Payment Reduction

In addition to PT, OT, and ST, 36 professions including (emergency medicine, anesthesiology, audiology, chiropractic, social workers) are targeted for a payment reduction in 2021. If the current law remains in effect, services performed by PT’s and OT’s will be reduced by 8%, ST by 5%. CMS says future legislation will address these proposed cuts.

CMS Coding Reversal

Effective 1/1/2020, PT and OT evaluation codes could not be billed (on the same day for same patient) as therapeutic activities (97530) and group therapy (97150). On 1/24/2020 CMS reversed this coding restriction allowing the same day billing of these codes.