Orthopaedic Section (OrthoPT)

American Physical Therapy Association (APTA)

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Payment Policy and Reimbursement

Are you challenged with keeping up to date on issues related to payment policy and payment reform in your practice? Do you find yourself wondering how payment reform will affect you and what do you need to know to be prepared? APTA is leading efforts to provide members with the most up to date information.

Payment Policy and Reimbursement/Payment Reform

  • Medicare Access and Chip and Reauthorization Act (MACRA): Current penalties under the Physician Quality Reporting System (PQRS), Electronic Health Records/Meaningful Use (MU), and the value-based payment modifier (VBM) will end at the end of 2018. The Merit-Based Incentive Payment System (MIPS) will replace the PQRS beginning in 2019, with bonuses paid to physicians on a sliding scale and penalties implemented up to 4% in 2019. The goal is to involve physical therapists in MIPS in the 3rd year. MIPS is very complex, particularly for outpatient services. Benchmarks will need to be established and technology will be a key component of implementation. Outcomes registries will be part of the process, and physical therapists will have to start focusing on the population health level.
  • Value-Based Payment: Currently, 30% of Medicare payments are tied to alternative payment models (APM). The goal is to increase the percentage of payments linked to APM’s to 50% in 2018, and 75% in 2020. The existing models are (1) episodic (i.e. Comprehensive Joint Replacement), and (2) population-based (ACO’s). Those participating in APM’s will receive 5% bonus payments if participating in an approved APM from 2019 to 2024.
  • MedPAC & Unified Payment System: the IMPACT act of 2014 requires the submission of standardized assessment data by long-term care hospitals, SNF’s, Home Health Agencies and Inpatient Rehabilitation facilities. Goals are to develop a common unit of service and uniform adjustment methodology. A common assessment tool will improve cost accuracy. The unified payment system will initially be based upon current practices and costs, but will transition eventually to a value-based care model.
  • Medicare Evaluation Coding: new coding structure will be implemented in January, 2017. APTA has launched an education campaign to help PT’s comply with the new codes. Payment for the 3 levels of complexity reflected in the evaluation codes will be at the same rate initially due to concerns over “up-coding”. CMS will collect data on code distribution prior to implementing a sliding payment scale for low, moderate or high complexity levels reflected in the new codes (97161-3). APTA conducted a live webinar on September 22, about the New Evaluation and Reevaluation Codes. The program can be reviewed at http://learningcenter.apta.org/student/MyCourse.aspx?id=9e3f1e4e-86c0-4564-abe8-c8b4081a46e9&programid=dcca7f06-4cd9-4530-b9d3-4ef7d2717b5d/ Free to APTA members.

Education resources developed by APTA to help keep you informed:

Orthopaedic Section, APTA, Inc.
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