by John Yodonise

December 22, 2018

2019 Changes Graphic

There are several important 2019 changes that you need to be aware of. Some are minor changes and some are major changes so here are the highlights for 2019 changes.


2019 Changes in the Medicare Cap

The Medicare Cap for 2019 is $2,040 for physical therapy and speech-language pathology services and $2,040 for occupational therapy services.

The hard cap has been repealed but there is a soft therapy cap so therapists must apply the KX modifier once the cap has been met to receive payment for medically necessary services.

The key phrase is medically necessary services, make sure your notes are complete and document the need for additional services past the cap.

The medical review cap remains unchanged at $3,000. If you provide therapy services past the $3,000 cap, a Medicare contractor may review your medical records to check for medical necessity.

Remember, the annual dollar limit for the caps reset on January 1,2019 so the KX modifier should not be used on claims until the soft cap has been reached. Improper use of the KX modifier may trigger and audit so be sure to use it correctly.


2019 Changes in CPT Codes

There are several CPT code changes that go into effect on January 1, 2019.

New Untimed Codes for OT and SLP

96112 - Developmental test by qualified healthcare professional; first hour
96113 - Developmental test by qualified healthcare professional; each additional 30 min
96121 - Neurobehavioral status exam by a qualified healthcare professional; each additional hour
96130 - Psychological test by qualified healthcare professional; first hour
96131 - Psychological test by a qualified healthcare professional; each additional hour
96132 - Neuropsychological eval by qualified healthcare professional; first hour
96133 - Neuropsychological eval by qualified healthcare professional; each additional hour
96136 - Psychological/neuropsychological test by qualified healthcare professional; first 30 min
96137 - Psychological/neuropsychological test by qualified healthcare professional; each additional 30 min
96146 - Psychological/neuropsychological test by standard instrument via electronic platform/auto result


New Timed Codes for OT and SLP

7151 - Behavior ID Assessment by qualified healthcare professional; each 15 minutes
97155 - Adaptive behavior treatment w/ protocol mod by a qualified healthcare professional; each 15 minutes
97156 - Family adapt behavior treatment by a qualified healthcare professional (with or without patient present); each 15 minutes
97157 - Multi-family group adapt behavior treatment by a qualified healthcare professional (without patient present); each 15 minutes
97158 - Group adaptive behavior treatment w/ protocol mod by a qualified healthcare professional (multiple patients); each 15 minutes


Retired Codes

96111 - Developmental Testing extended, with interpretation and report
64550 - Tens unit application


CMS Giveth and CMS Taketh Away in 2019


Functional Limitation Reporting

PTs, OTs, and SLPs do not have to complete Functional Limitation Reporting in 2019 for Medicare Part B and Railroad Medicare beneficiaries.

However, commercial payers (Medicare Advantage plans and Worker's Compensation plans) that use the Functional Limitation Reporting system are not affected by this change and may still require FLR codes. You need to check with any commercial payer to see if they will discontinue FLR codes.

Please note: The 42 non-payable FLR codes will remain active for one year (until 2020) to allow providers and insurers time to remove them from their systems and make any necessary updates. To remove the FLR code requirements from your EHR system, you will need to edit your insurance companies. If you are using WebPT, you must uncheck the Apply Functional Limitation Reporting in each insurance company that no longer requires Functional Limitation Reporting.

Another note: Six of the FLR codes (G8980, G8983, G8986, G8989, G8992, and G8995) can be used for MIPS reporting (see below) so they may continue to be used if you participate in the MIPS program.

[2020 Update] Including the FLR codes in claims for 2020 will cause your claims to be rejected for an invalid code so be sure to remove any FLR codes in claims after December 31, 2019.


MIPS (Merit-Based Incentive Payment System)

Physical Therapists are eligible to participate in the MIPS program starting in 2019. If you choose to participate, you can receive a penalty of up to 7% or a bonus of up to 7.5% on claims two years later (2019 results will affect your 2021 payments).

You will be given an overall MIPS score ranging from 0 to 100 points and the number of points you achieve will determine your penalty or reward.

Whether you need to participate or not in the MIPS program depends on three threshold tests:

  1. Your Medicare charges for the look-back period are less than $90,000
  2. You treat less than 200 beneficiaries
  3. You perform less than 200 covered services

If you meet all three criteria, you are exempt from the MIPS program but can choose to voluntarily report to get feedback from CMS.

If you exceed one or two of the criteria, you can choose to opt-in to the MIPS program or voluntarily report.

If you exceed all three of the criteria, you MUST participate in the MIPS program.

CMS has set up a website at http://qpp.cms.gov/participation-lookup where you will be able to check your participation level based on the latest look-back period (October 2017 through September 2018). CMS has estimated that only 10% of the physical therapy practices will be required to participate n the MIPS program.

There is a lot of information available at http://qpp.cms.gov about the MIPS program that will help you decide what is best for your practice. There are many details to the program that go beyond the scope of this post. If you qualify, CMS has free consulting services available on the website that can assist you in making decisions about the MIPS program.


Medicare Fee Schedule and Therapy Assistants

Starting in 2022, Medicare will pay 85% of the fee schedule for PTAs, OTAs, and COTAs when they perform 10% or more of any service. New modifiers CQ and CO will be used to report services performed by the PTA, OTA, or COTA.

While this change is still three years away, it will directly impact the bottom-line of many practices and will require new reporting policies and procedures so it is best to start planning now for the change.

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