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 2019 Medicare Part B Payment Rule Offers Some Positives for SNFs

Skilled nursing facility (SNF) payment experts say there are positive takeaways from a final rule issued by the Centers for Medicare & Medicaid Services (CMS) updating policies and payment rates associated with services billed under the Calendar Year (CY) 2019 Medicare Physician Fee Schedule. The rule also applies to Part B therapy services furnished in SNFs.

While there are parts of the rule that remain a challenge to SNFs, Daniel Ciolek, associate vice president of therapy advocacy for the American Health Care Association (AHCA), tells Provider that “overall, the final rule either improved proposed policies impacting SNF providers and residents, or at least maintained the status quo, meaning we still have some work to do.”  

In looking at how therapy policy moved in a positive direction on several fronts, he says first off CMS reminded providers that the Bipartisan Budget Act of 2018 (BBA) repealed the per-beneficiary Part B therapy caps. The rule noted that the BBA also continued the use of the KX medical necessity modifier once the cost for therapy exceeds a certain threshold (set at $2,040 for 2019) for physical therapy (PT) and speech-language pathology (SLP) services combined or occupational therapy (OT) separately, and implemented a targeted medical review program for some PT/SLP and OT services over $3,000 per year.  

Second, Ciolek says CMS acted on AHCA and other stakeholder comments pointing out that the proposed approach to implementing therapy assistant provisions, enacted as a pay-for in the cap repeal legislation, was burdensome and would impose greater payment reductions than intended by Congress. 

“In the final rule, CMS established new therapy assistant claim modifiers that will be required starting in CY 2020 and described how the BBA-required 15 percent therapist assistant payment reduction starting in 2022 would be applied,” he says. 

Initially, CMS proposed to apply the payment adjustment any time a therapy assistant provided any amount of care, while the final rule offered a more flexible 10 percent threshold before the payment adjustment for a service would apply.

“Although we didn’t get all we asked for and there are some remaining unanswered questions about how this will be applied, we appreciate that CMS listened to our concerns about how the congressional intent should be applied,” Ciolek says. 

CMS indicated it will be working with stakeholders to develop clinical coding scenarios for next year’s rulemaking, he adds.      

A third positive on therapy in the rule is consistent with CMS’ “Patients over Paperwork” initiative as the agency eliminated the burdensome claims-based functional reporting requirements for Part B therapy services. Instead, starting January 2019, SNFs will no longer be required to append the following nonpayable functional limitation G-codes—G8978 through G8999 and G9158 through G9186 or the following severity modifiers—CH through CN—to any outpatient therapy claim. 

Ciolek says another good result from the rule, although not related to therapy, is that CMS modified and delayed implementation of proposed changes to physician evaluation and management payment codes. As proposed, these changes would have significantly cut payments to geriatricians and other physicians that often care for SNF residents. 

Instead, the final rule provides some protections from the payment cuts and delays implementation for two years. “AHCA agreed with physician groups in opposing the proposed policy as it would have had a chilling impact on the available SNF physician workforce,” he says. “The delay offers time to further improve the policy.” 

On two other fronts, CMS did not act on suggestions from AHCA concerning the Part B payment rule. In one, AHCA requested that CMS align the SNF telehealth restrictions (currently once per 30 days) with other post-acute care settings, such as inpatient rehabilitation facilities (currently once per three days). This request was made so that SNFs could better care for residents in place as opposed to discharging them to hospitals. CMS chose to maintain the status quo on this measure.

Second, Ciolek says AHCA asked that CMS consider developing a path for SNF Part B therapy services to be included in the Merit-based Incentive Payment System (MIPS), which provides incentive payment adjustments for meeting quality requirements, but CMS also decided to keep the final rule in line with the earlier draft and did not act.

“Both of these policy topics are complex and deserve more attention from policymakers. AHCA will continue to explore opportunities to advance these policies that would incentivize better care for our members’ residents,” he says.

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