1. Payment Policy Updates Fall 2019
Steffes & Associates Consulting Group, LLC

2. WI Medicaid
Updated PA Process for 0-21 Years old

3. Medicare- Med B Functional Reporting- G-Codes stopping 1/1/19
No fee schedule updates in !
Merit-based Incentive Program “MIPS” Opportunities:
Private Practice Therapists ONLY in 2019
Based on individual PT NPI + Tax ID for Op Facility
Low Volume Threshold> will likely affect only 5% of PP PTs!
Qualified Providers: PTs, OTs enrolled in MC (NPI)
Bill out > 200 MC allowable Services (Units)
See > 200 Unique MC pts/yr (Based on 2016 data)
Receive > $90,000 allowable MC payments
Optional Group Participation if meet 1 Criteria Above
Possible Punitive adjustment of 7%- for 2 year following year’s claims
Possible incentive UP to 7%

4. Medicare Updates
Congress reduced 2019 Medicare update to Fee Schedule from .50% to .25% :
Alternative Payment Models: Eligible for 5% bonus
MIPS: Eligible for +/- payment adjustment
2026 and beyond:
Providers in Advanced APM will receive .75% update
MIPS providers will receive .25% update inflationary adjustment resumes
New Modifiers will be added in 2020 for services where PTAs provide 10% or more>

5. CAP
Therapy CAP- increased the KX modifier threshold by 1.5% and rounded up to give rehab therapists a shiny new soft cap of $2,040 for PT and SLP services combined and $2,040 for OT services.
Therapy Threshold for targeted medical review (MR) threshold will remain at $3,000, and, as has always been the case, “some, but not all claims exceeding the MR threshold are subject to review.”

6. Therapy CAP Exceptions Process EXTENDED!
2019 Therapy Threshold= $3000
KX Modifier continues after the Threshold
Manual Medical Review may be applied
RAC’s are prohibited from doing the Reviews
CMS has contracted with Strategic Health Solutions to complete these reviews post-payment
Chosen based on High Claims Denial %
Aberrant Pattern of Billing
Newly enrolled or new to Part B

7. MIPS- Private Practices Only 2019

8. MIPS Reporting looks a lot like PQRS
Meds on Eval
BMI on Eval
Pain on eval & re-eval
Functional Measure on Eval & Re-eval
Falls Risk & Plan on Eval (Combined now)
You must be compliant not report code that is not
Can do Claims Based Reporting if you have < 15 Providers- RISK Increase!
Must use Registry above that threshold
APTA has Outcomes Registry
CURRENTLY WAIVED!!!
$299/Therapist/yr members; $399/Therapist/yr non-members’
Some EMR Integration Automation
Ability to track performance
Additional Important PT outcomes info

9. Anthem BCBS- AIM

10. AIM

11. AIM Request

12. AIM Challenges CONTACT:
program related questions

13. Network Health Plan: eviCore

14. Sample Therapy corePathSM Pathway
Initial Requests
Case Related Questions:
Identify new care vs. continuing care based on treatment area, not time
Identify primary area of treatment
First indicator of complexity – second unrelated treatment area 1 2 3

15. Sample Therapy corePathSM Pathway
Initial Requests, continued….
Initial Clinical Questions:
Enter functional score, if available
Oswestry Index
Neck Disability Index
LEFS
Dash / QuickDASH
Incorporates ROM, Strength, Pain, etc.
Complexity:
Neural signs
Chronicity 4 5 6
High Potential for Immediate Approval When Pathway is Completed!

16. Sample Therapy corePathSM Pathway
Follow-Up Request
Follow-Up Clinical Questions:
Current and Previous Functional Score
Complexity Question – Neural Signs
Progress
Validated scores have MCD (minimal clinical difference) as progress indicator
Clinical Assessment 1 2 3
Be clear – this is for a low back condition. Actual number of questions will differ per request, but the concept is the same, only key clinical information is collected.
High Potential for Immediate Approval When Pathway is Completed!

17. Prior Authorization Process
What is used to determine if services are medically necessary?
Clinical Criteria
Available
Synthesis of research, guidelines, expert consensus
Updated annually and approved by the Health Plan
Clinical Information
Should be current
Adult within the prior 14 days
Peds within the prior 20 days; standardized tests 1x/year
Complete the questions
If there is no information or information has gaps, it will delay the decision
Worksheets are available at to guide your clinical collection

18. Prior Authorization Process
Requesting Authorization
For the first request
Evaluate the member before you request prior authorization
Evaluation codes do not require prior authorization
Submit your request within 7 days of the requested start date
If additional care is needed
You may submit your request as early as 7 days prior to the requested start date
This allows time for the request to be reviewed and prevents a gap in care
Remember to provide complete, current clinical information including patient reported functional outcome measures
Notes: Requests with a start date of > than 7 days in the future will not be accepted. If the member is away from therapy, reassess the condition once therapy has resumed. This allows you to provide current information to allow eviCore to determine medical necessity of ongoing therapy.

19. Prior Authorization Process
Timely Filing
Security Health Plan allows providers to evaluate and treat at the initial visit.
The evaluation code does not require prior authorization but treatment does.
If treatment is provided during the evaluation visit, you have 7 days from the date of service to submit your request for authorization for the initial treatment.
Authorization for treatment beyond the initial visit must be requested prior to providing care.
Retrospective requests will be accepted up to 7 business days. Please note that any cases after 7 business days will be expired.

20. Wi Worker’s Compensation
Fee Schedule and Policy Updates

21. Lynn Steffes, PT, DPT Steffes & Associates Consulting Group, LLC