Physical Therapy Classification and Payment System (PTCPS)

1. Physical Therapy Classification and Payment System (PTCPS) Andre Ishmael University of Central Florida Doctor of Physical Therapy Class of 2014

2. Current System • The current system is a fee-for-service and procedural-based payment system. • With Medicare, once outpatient therapy services have been given, outpatient therapy provider facilities and professional offices submit their claims to their regional Medicare Administrative Contractors who process their claims. • Complaints – • Too much of trying to justify intervention getting paid for. • Some payers pay for certain intervention while some don’t.

3. The Balanced Budget Act of 1997 • Ever since the Balanced Budget Act of 1997 which placed payment caps on outpatient PT and SLP combined, with outpatient OT separately, the APTA started looking towards a different payment system. • Some proposed ideas include: • Impose volume controls, • Refine/expand claim line procedure edits, • Create alternative applications of the original payment caps (e.g., separate into three caps, merge into a single cap, create facility or condition-specific caps), • Track and limit therapy expenditures on a different basis than the current annual per beneficiary basis (per-episode), • Develop a tiered cap that allows for higher limits for targeted patients with greater needs, • Intensify and expand medical review efforts, • Eliminate the outpatient therapy caps altogether to allow other alternatives to function, • Continue the caps with exceptions for services identified as medically necessary, and • Continue the caps but reinstate a form of the ‘Manual Process Exceptions’ procedures applied during CY 2006 which required pre-authorization from the contractor beyond predetermined benchmark threshold limits.

4. Development of Alternative Payment System for Physical Therapy Services • Computer Sciences Corporation (CSC) was awarded a 2 year contract by CMS to develop alternatives to the current therapy caps; this is meant to improve quality of services and encourage that payment is only rendered for medically necessary services. The PTCPS model hopes to benefit both providers and payers of rehabilitation services.

5. The APTA’s alternative payment system for physical therapy services aims to reform payment for outpatient physical therapy services by transitioning from the current fee-for-service, procedural-based payment system to a per session payment system. • Alternative payment system for physical therapy services would reduce current physical therapy procedural codes from about 76 codes to 12 codes based on complexity. • 3 Evaluation Codes (1-3) • 9 Examination and Intervention Codes (4-12)

6. Evaluation Based on Clinical Complexity of the Evaluation

7. Evaluation – Limited/Problem-Focused - 1 • A limited examination of the affected body area or system. • Clinical presentation with stable characteristics of patient's condition, complaints, cognitive status, and with minimal to absent safety concerns, • A problem focused history, limited examination, straightforward clinical decision making with no personal factors or comorbitities that impact the condition being evaluated, • Limited use of standardized tests and measures is required to establish or update a plan of care addressing 1 or more similar impairments, activity limitations and/or participation restrictions, • Initiation of or updates to the plan of care, including goals and the selection of interventions is documented by a physical therapist, and • Plan of care requires minor or no referral or coordination, consultation or communication with other health care professionals.

8. Evaluation – Moderate/Detailed - 2 • An extended examination of the affected body area(s) and other symptomatic or related system. • Clinical presentation with evolving or changing characteristics of patient's condition, complaints, cognitive status, and with moderate safety concerns, and potential for functional decline or delayed progress, • A detailed history and examination, and consideration of impact of other health conditions or impairments on functional recovery with documentation of two or less personal factors and/or comorbidities that impact the condition(s) being evaluated, • Use of standardized tests and measures, the complex consideration of the interaction of multiple health conditions or impairments on functioning and, the establishment of a detailed plan of care or update of an established plan of care addressing impairments, activity limitations and/or participation restrictions as identified by standardized functional assessment instrument(s), • Initiation of or updates to the plan of care, including goals and the selection of interventions is documented by a physical therapist, and • Initiation of or updates to the plan of care, requiring some referral to, coordination, consultation and/or communication with other providers.

9. Evaluation – Significant/Comprehensive - 3 • A general multisystem examination or a complete examination of a single system. • Clinical presentation with unstable and unpredictable characteristics of patient's condition, complaints, cognitive status, and with substantial risk for diminished safety, • Detailed history and examination using standardized tests and measures (including performance based tests and measures), and complex consideration of the interaction of multiple health conditions or impairments on functioning, with documentation of 3 or more personal factors and/or comorbidities that impact the condition(s) being evaluated, • Establishment of a comprehensive plan of care or the update of an established plan of care addressing impairments, activity limitations and/or participation restrictions as identified by functional assessment instrument(s), • Initiation of or updates to the plan of care, including goals and the selection of interventions is documented by a physical therapist, and • Initiation of or updates to the plan of care, requiring referral to, coordination, consultation and/or communication with other providers.

10. The Visit/Session Based Examination (Patient Severity)and Intervention (Intensity of Visit)

11. Examination and Intervention Code 4: Limited Patient Severity, Therapy Intervention Limited • Examination- clinical presentation is stable with minimal safety issues due to health and/or cognitive status, • Patient receives limited interventions (typically 30 minutes or less), a portion of which involves individualized interaction between the qualified health care professional and the patient, and • Patient response to intervention is monitored and adjusted based on clinical information/data gathered.

12. Examination and Intervention Code 8: Moderate Patient Severity, Therapy Intervention Moderate • Based on examination clinical presentation demonstrates evolving or changing characteristics to patient condition, complaints, cognitive status, with moderate safety concerns, • Patient receives moderate interventions (typically 31-45 minutes), a portion of which involves individualized interaction between the qualified health care professional and the patient, and • Clinical problem solving or decision making occurs throughout the intervention based on changes in the patient's status, response to treatment, and whether the planned procedure or service should be modified.

13. Examination and Intervention Code 12: Significant Patient Severity, Therapy Intervention Significant • Based on examination, clinical presentation demonstrates unstable and unpredictable characteristics to patient condition, complaints, and/or cognitive status affecting safety and requiring evaluation or reevaluation during the session, • Patient receives significant interventions (typically more than 45 minutes of 1:1 interventions involving active patient participation, or modality interventions), and • Clinical decision making occurs throughout the intervention based on changes in the patient's status, response to treatment, and whether the planned procedure or service should be modified.

14. SWOT Analysis

15. Strengths • Places more value on quality of care rather than quantity • Episode based care vs. fee-for-service • Less codes to remember • Time saving for outpatient clinics since PTs will submit a single code for the treatment session versus multiple codes for each intervention • Improve utilization of PT skill • Leads to a stronger profession • Based on patient needs • Not money or productivity

16. Weaknesses • Financial instability • Payment levels are yet to be determined • Profitability still required to maintain a clinic • Overhaul of current payment system • New billing systems/software initially will cause increased admin burden • WebPT • Very subjective definitions • Increased potential for fraud and abuse • Does not clearly state role of PTAs • PTs are required to interact with every pt (possible strength) • PTAs could be potentially limited to seeing limited-moderate patients • Will you be able to see more than 1 patient/hour if limited intervention, and could this possibly include Medicare patients that are in this category

17. Opportunities • More clinician autonomy • Intervention use more flexible • Easier to track when a patient will surpass cap due to overall flat rate per session • Clinics are more likely to expand the kinds of patients they see (neuro, peds, etc) to make themselves more profitable • Opportunity to standardize payment system between private insurances and Medicare • Potentially could allow patients to exceed the therapy cap and receive continued therapy based on the severity of the patient being documented every session vs. KX modifier and exceptions process • Increased integration of PTs with other professions • Working more with PTAs, ATs, Massage Therapists, Exercise Physiologists, etc.

18. Threats • Time commitment • At least 2-4 more years minimum • Medicare cap still in place • Kx modifiers still required • Opens chance for fraud and abuse by clinicians • Due to need to learn new system • (accidental or purposeful) • Increased documentation time • Increased need for outcome measures • Will outside payers have the ability to deny reimbursement for the entire session versus just units for a session

19. Surveys

20. Surveys

21. Timeline

22. Resources • American Physical Therapy Association. (2012). An alternative payment system for physical therapy services. • American Physical Therapy Association. (2012). Guiding principles • Ciolek, Daniel E. and Hwang, Wenke. (2010). Short Term Alternatives for Therapy Services (STATS) Task Order: Final Report on Short Term Alternatives. • Computer Sciences Corporation. (2010). Short Term Alternatives for Therapy Services (STATS) Task Order: Final Report on Short Term Alternatives. Baltimore, MD: D. Ciolek, W. Hwang • http://www.apta.org/PTCPS/ • Levine, S. (Director) (2013, August 19). Value In Healthcare. Management of Physical Therapy Services II. Lecture conducted from University of Central Florida, Orlando. • Levine, S. (Director) (2013, August 26). Medicare Benefit Policy. Management of Physical Therapy Services II. Lecture conducted from University of Central Florida, Orlando.