2021 Proposed CMS Rule For PTs, OTs, SLPs

2021 will have quite a few changes for CMS in store

Philosophers who studied Plato as well as Hermes quoted that “the only thing consistent in this great world of ours is change”. It is known in physics and in science, that nothing stays the same, that everything is in a state of flux, meaning moving from one energy state to another. We see this all of the time in healthcare. It should come as no surprise that 2021 is posing for yet more changes, particularly to CMS.

Each year near the end of July, the Centers for Medicare and Medicaid Services (CMS) releases a document with all of the proposed policy changes to be implemented in the coming year. The proposed rule for 2021 was released and included some legislative changes that are indisputable wins for PTs, OTs, and SLPs as well as some changes and payment cuts that are potentially detrimental for the entire industry.

Some of the highlights of the changes are:

Increased Reimbursement For Evaluation Codes

CMS announced its decision to revalue CPT codes in order to direct more payment toward evaluation and management (which includes codes therapists rarely use). In the 2021 proposed rule, CMS acknowledged that PT, OT, and SLP evaluation services are similar to E/M codes (i.e., they both require assessment and management work) and proposed a modest payment bump for those services. CMS proposed to apply an RVU increase (estimated at 28%) to the following codes: 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 92521, 92522, 92523, and 92524. 

As per CMS: “We are proposing to adjust the work RVUs for these services based on a broad-based estimate of the overall change in the work associated with assessment and management to mirror the overall increase in the work of the office/outpatient E/M visits. We calculated this adjustment based on a volume-weighted average of the increases to the office/outpatient E/M visit work RVUs from CY 2020 to CY 2021. Details on this calculation are available as a public use file on the CMS website at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFSFederal-Regulation-Notices. We are proposing to apply that percentage increase, which we estimate to be approximately 28 percent, to the work RVUs for the therapy evaluation and psychiatric diagnostic evaluation services codes. We believe that it is important to the relativity of the PFS to revalue these services to reflect the overall increase in value associated with spending time assessing and managing patients, as reflected in the changes to work values for the office/outpatient E/M visits, particularly in recognition of the value of the clinicians’ time which is spent treating a growing number of patients with greater needs and multiple medical conditions.”

Physical Therapy And Occupational Therapy Will Be Subject To A Large Payment Cut

While CMS plans to increase payments for evaluation codes, payments across other codes are estimated to be reduced by 10.61%. The net result is a cut to Medicare reimbursement of approximately 9% starting January 2021. 

The announcement of these cuts has been a disappointing to news to providers and patients. “If implemented in its current form, these cuts could drive physical therapy providers out of business, particularly those who deliver care to underserved minority communities and older Americans — two populations that have already been disproportionately impacted by the public health emergency,”  said Nikesh Patel, PT, executive director of the Alliance for Physical Therapy Quality and Innovation, in a statement. 

“We are deeply disappointed that — despite unified warnings from lawmakers, specialty providers, and other stakeholders about the potentially devastating impact of these cuts in the midst of a global pandemic — CMS nonetheless chose to move forward with Medicare specialty reimbursement reductions in 2021,” Patel added. 

PTAs and COTAs Will Be Allowed To Provide Maintenance Therapy

When CMS published the home health final rule earlier this year it stated that PTAs and COTAs are able to provide maintenance therapy to Medicare beneficiaries in inpatient settings. In order to align this policy across the board CMS is proposing to allow this regardless of setting. As per CMS: “We do not believe that the therapist-only maintenance therapy requirement is needed in the case of outpatient physical or occupational therapy services, and instead believe that it would be appropriate for an OT or PT to be permitted to use their professional judgement to assign the performance of maintenance therapy services to an OTA or PTA when it is clinically appropriate to do so.”

CMS goes on to state: “As such, we propose to allow, on a permanent basis, therapists to delegate performance of maintenance therapy services to an OTA or PTA for outpatient occupational and physical therapy services in Part B settings beginning January 1, 2021. This proposal would better align our Part B policy with that in SNFs and HH paid under Part A where maintenance therapy services may be performed by a therapist or a therapy assistant. Since our regulations at §§ 410.59, 410.60, 410.61, 410.62 and 424.24, do not now distinguish between rehabilitative and maintenance therapy services, we are not proposing to amend them. Instead, we propose to revise sections 220.2, 230.1 and 230.2 of chapter 15 of the Medicare Benefit Policy Manual to clarify that PTs and OTs no longer need to personally perform maintenance therapy services and to specifically remove the prohibitions on PTAs and OTAs from furnishing such services. Therefore, we believe our proposal to allow PTs and OTs to delegate maintenance therapy services to their supervised assistants is in keeping with Executive Order #13890 and appeals by respondents to our request for feedback on scope of practice that followed, rather than the alternative option of maintaining the pre-COVID-19 policy of requiring PTs and OTs to personally furnish them, after the COVID-19 PHE is ended. We note that therapists and therapy providers should consult the CQ and CO modifier policies to consider whether these modifiers should be applied to claims for services furnished in whole or in part by PTAs and OTAs which will, beginning January 1, 2022, be paid at 85 percent of the amount that would otherwise apply for the service, as required by section 1834(v) of the Act which was added by section 53107 of the Bipartisan Budget Act of 2018. See the CY 2020 PFS rulemaking for policies related to the application of CQ and CO modifiers and the associated regulatory requirements (84 FR 40558 through 40564 (proposed rule) and 84 FR 62702 through 60708 (final rule)).”

Students can document:

In the proposed rule it is clarified that therapy students can document in the medical record. For this, the billing therapist must review, verify, sign and date the documentation.

OTs, PTs, and SLPs Will Not Have Permanent Telehealth Privileges

The pandemic in 2020 brought quick implementation and reimbursement of telehealth across the nation. Unfortunately, the 2021 proposed rule reports that CMS does not plan to extend this to permanent telehealth billing privileges for therapy. The document reads: “With regard to the physical therapy, occupational therapy, and speech-language pathology services in Table 11, we have received a number of requests that we add therapy services to the Medicare telehealth services list. In the CY 2018 PFS final rule, we noted that section 1834(m)(4)(E) of the Act specifies the types of practitioners who may furnish and bill for Medicare telehealth services as those practitioners under section 1842(b)(18)(C) of the Act. Physical therapists (PTs), occupational therapists (OTs) and speech-language pathologists (SLPs) are not among the practitioners identified in section 1842(b)(18)(C) of the Act. We stated in the CY 2017 PFS final rule (81 FR 80198) that because these services are predominantly furnished by PTs, OTs, and SLPs, we did not believe it would be appropriate to add them to the Medicare telehealth services list at this time. In a subsequent request to consider adding these services for 2018, the original requester suggested that we might propose these services to be added to the Medicare telehealth services list so that payment can be made for them when furnished via telehealth by physicians or practitioners who can serve as distant site practitioners. We stated that since the majority of the codes are furnished over 90 percent of the time by therapy professionals who are not included on the statutory list of eligible distant site practitioners, we believed that adding therapy services to the Medicare telehealth services list could result in confusion about who is authorized to furnish and bill for these services when furnished via telehealth.”


Due to the COVID-19 public health emergency, CMS adopted an interim policy that revised the definition of direct supervision, allowing providers to supervise virtually. CMS has proposed to extend this policy until either the end of the public health emergency or December 31, 2021. 

Some Changes In The MIPS Program

  • MIPS Value Pathways

These are the “participation framework” that unites the measures and activities of the MIPS program. CMS was planning to have providers transition to the value pathways in 2021, however they are now planning to push back the timeline until 2022.

  • Low-Volume Threshold and Category Weighing

CMS has not proposed changes to the low-volume threshold criteria. This means that clinicians will still be mandated to participate in MIPS if they: 

  • submit Medicare Part B claims for more than 200 unique beneficiaries,
  • submit Medicare Part B claims for more than 200 services (CPT codes), and
  • bill more than $90,000 in allowable charges to the Medicare Part B program.

The agency also proposed to retain the MIPS category reweighing of 85% for the Quality Measure domain and 15% for the Improvement Activities domain for PTs, OTs and SLPs.

  • Quality Category

There are several changes to measure sets in the quality category. CMS has proposed adding measures 283 and 286 (two measures of dementia) to the PT/OT specialty set). They will remove measure 282 (a dementia measure) due to its similarity to another measure. Also, they will add measure 134, which is a depression screening, to the SLP specialty set.

They have also proposed “substantive changes” to almost all single clinical quality measures. We will need to keep an eye on this, as it has not yet been finalized. 

  • Performance Threshold

Due to the pressure that the pandemic has put on the healthcare system, CMS has proposed to reduce the performance threshold for 2021. For this, MIPS participants would need to score 50 or greater points to achieve a neutral or positive adjustment (as opposed to the 60 points that were previously required). Exceptional performance required points would remain the same (85 points required).

Other Remote Services

Under this, PTs, OTs, and SLPs will be permitted to provide “brief online assessment and management services and virtual check-ins.” Services via telephone were not included in the proposal. CMS proposed creating two new HCPCS G-codes that are much like virtual check-in codes, have the same value, and are specifically intended for clinicians who do not generally bill E/M services. As per the document the codes are:

  • G20X0 (Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment.) 
  • G20X2 (Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion)

There is still time for changes to be made and the document to be altered. Clinicians are encouraged to keep their eyes on the advocacy efforts taking place over the next few months.

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