Medicare roundup for 2017: Evaluation codes, Quality Payment Program and more

A top priority for PTPN’s Political Action program this year has been commenting on and keeping you up-to-date on the Centers for Medicare and Medicaid Services (CMS) proposals for 2017 that affect therapy professionals and practices. There were many! This is our year-end roundup of the new CMS policies for 2017, and how CMS responded to PTPN’s and your concerns in the final rule.


New Evaluation Codes: New Codes for PT/OT, All Valued the Same

CPT codes 97001 through 97004, the PT and OT evaluation and re-evaluation codes, have been eliminated for 2017. In their place are eight new CPT codes: three PT evaluations, three OT evaluations, and one re-evaluation each. These new evaluations codes are based on complexity and intensity of the evaluation: low, moderate and high. The AMA originally created the new evaluation codes with different unit values. However, CMS has valued these PT and OT evaluation codes at the current levels, instead of valuing them individually to reflect the level of complexity, as requested by PTPN and other commenters. So there will be no change in the evaluation reimbursement from 2016, just new codes to use. CMS is worried about up coding, and is unsure if the use of the new evaluation codes will maintain budget neutrality.

However, CMS did respond to the argument of PTPN and other stakeholders that it should adopt the AMA’s proposed value of the PT re-evaluation code, which will increase in 2017 over 2016. CMS also hinted that they plan to collect and analyze utilization data of the complexity levels on the new codes for possible future rulemaking. They go on to state that if they were to “value each code in the PT and OT evaluation families individually, [they] would seek objective data from stakeholders to support the utilization crosswalks” to achieve work neutrality. No timeline for reassessment was given.

PTPN is having a members-only webinar on December 14 detailing the new codes, their usage and documentation, as well as a bit about the new CMS QPP (see section below). PTPN members can contact their regional PTPN office if they have misplaced their invitation. We will also be posting information on this topic on PTPN’s website in the members-only section.


The Quality Payment Program: PQRS is Gone, QPP Replaces it, But Not Yet for Therapists

Currently, Medicare measures the value and quality of care through a patchwork of programs, such as the Physician Quality Reporting System (PQRS), the Value Modifier Program (VM), the Medicare Electronic Health Record (EHR) Incentive Program, and others. With the passage of MACRA, Congress streamlined these various programs into a single framework in order to transition clinicians from volume-based payments to payments based on value and quality. For 2017, these programs are gone, and the Quality Payment Program (QPP) has taken their place. There are two parts to the QPP: the Merit-based Incentive Payment System (MIPS) and the Advanced Alternative Payment Models (APMs). Therapists are not participating providers in QPP in 2017 and 2018, getting at least a two-year break (CMS may require participation in 2019), but you can report voluntarily.

PQRS is gone as of 1/1/17, so PQRS measures for items like Fall Risk, Medications, BMI, etc., are discontinued. PQRS does live on in the potential penalties for 2017 and 2018 based on 2015 and 2016 reporting. However, Functional Limitation Reporting (FLR) is still with us! So therapists do have to report the “G codes” and modifiers for current, projected, and discharge status for: Mobility, Changing and maintaining body positions, Carrying and moving objects, Self-care, and Other.

As part of our comments to CMS, PTPN commented on the low-volume threshold for participating in the MIPS portion of QPP. We wanted to ensure that practices which only see a small volume of Medicare patients were not overly burdened. CMS heard and responded by raising the threshold for required participation to only those Part B providers that have both 100 patients and $30,000 in allowed charges in a year. This can be per therapist (or per office if you register as a group). So unless that changes in 2019, some therapists may still not be required to participate depending on the caseload.

One other comment and response worth mentioning is regarding certified electronic health records (CEHR). In MIPS, CMS is highly valuing the use of a CEHR, basically requiring it to be eligible for a bonus and avoid penalties. However, physicians had access to CMS funds to assist with the purchase of a CEHR; therapists did not. This strong focus on CEHR will be an obstacle and concern for physical therapists when it comes time for them to be included in MIPS. CMS did respond to some of our concerns and recognized that eligible clinicians will have a spectrum of experiences with using CEHR technology, therefore it would “consider how such eligible clinicians would be scored for each performance category in future rulemaking.”



The Medicare therapy cap amount has been updated to $1980 for 2017. The therapy exception process expires 12/31/17. In order to repeal the therapy cap or extend the exceptions process, corrective legislation must be passed before that date.

For therapists in California, CMS greatly expanded the number of geographic reimbursement areas (GPCIs), so you may see a slight change in your Medicare reimbursement due to the new GPCI factors.

As previously reported, CMS has identified ten potentially misvalued codes commonly used in physical therapy: electrical stimulation (97032), ultrasound therapy (90735), therapeutic exercises (97110), neuromuscular reeducation (97112), aquatic therapy/exercises (97113), gait training therapy (97116), manual therapy (1/regions) (97140), therapeutic activities (97530), self-care management training (97535), and electrical stimulation other than wound (G0283). Since early October, surveys have been sent to practitioners in order to gather data on these ten codes. In the final rule, CMS acknowledged that physical therapy organizations are currently working with the AMA to survey and submit changes to certain CPT codes and went on to confirm that they are expecting the valuation analysis and recommendations from the AMA in February 2017. CMS indicated that they plan to include a valuation discussion of the ten potentially misvalued codes in the 2018 Medicare physician fee schedule update.

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