Physical therapists must contract with Medicare to treat Medicare patients—and the rules aren’t always easy to follow. Here’s the physical therapists’ guide to Medicare.
Here’s the physical therapists’ guide to Medicare—everything you need to know about enrolling, treating patients, and billing under Medicare.
Heidi Jannenga 5 min read March 2, 2024
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In the ever-evolving healthcare landscape, understanding the intricacies of insurance regulations and coverage is crucial for a successful business. For physical therapists, learning to navigate the complexities of Medicare is a necessity and a valuable asset in ensuring optimal patient care and practice sustainability. But most clinicians don’t have the time—let alone desire—to sit around and read through every change and new regulation. That’s why we have created the physical therapists’ guide to Medicare: to offer one source of truth to get started treating patients and close the textbook or web browser.
Before diving into the physical therapists’ guide to Medicare, let’s discuss what Medicare is exactly. Administered by the Centers for Medicare and Medicaid Services (CMS)—a component of the Department of Health and Human Services (HHS)—the Medicare program covers Americans aged 65 and older who have worked and paid into the system as well as younger people with disabilities and those with end-stage renal disease or amyotrophic lateral sclerosis (ALS).
According to the authors of this article, “Medicare is designed to absorb risk,” whereas “commercial insurers will always seek to minimize their exposure to risk.” As a government program, Medicare provides coverage to healthy individuals and those who currently have—or may develop—expensive or complex medical issues requiring significant medical intervention. Commercial insurers, on the other hand, must “protect [their] business interests by avoiding those most likely to use medical care.”
As of September 2022, Medicare was providing coverage to more than 65 million Americans. In 1996, this number was only 19.1 million. According to a report published by The Commonwealth Fund, on the whole, Medicare covers about 75% of its beneficiaries’ healthcare costs, and about 70% of beneficiaries are between the ages of 65 and 85. Medicare has a resource for eligibility requirements for prospective enrollees.
Medicare has four parts: A, B, C, and D—and, “each covers a distinct set of services and benefits.” Additionally, there are supplement plans that fill in Medicare coverage gaps. Here’s what you need to know about each of Medicare’s parts:
Medicare Part A is inpatient hospital insurance and Part B is supplementary medical insurance. Together, they form what is referred to as “Original Medicare.” While Part A covers inpatient hospital and skilled nursing facility care, home health care, and hospice care, Part B covers doctor’s services, rehab therapy services, and other outpatient care and supplies not covered under Part A.
If you’re in private practice and accept Medicare beneficiaries, you most likely provide services that fall under Medicare Part B. It’s important to note that Medicare does not cover Medicare Part B services for patients receiving Part A services. Thus, be sure to ask all patients about concurrent care.
In most cases, Original Medicare beneficiaries can choose their provider and facility—as long as that provider is enrolled in Medicare and accepting new patients. Most patients don’t pay a premium for Part A but pay a premium for Part B (based on income level and Social Security benefits). Patients usually pay a deductible and coinsurance when they access both Part A and B services.
Medicare Part C—a.k.a. Medicare Advantage (MA)—plans are provided by private companies that have received approval from Medicare to offer all-in-one hospital and medical insurance. Prescription drug coverage is also usually bundled in Part C plans—and many Part C plans offer additional coverage beyond what original Medicare provides, including dental and vision. For some patients, MA plans may be more cost-effective than Original Medicare. While Medicare funds MA plans, questions about coverage, out-of-pocket costs, billing, and referrals should be directed to the providing company.
Prescription drug coverage falls under Medicare Part D. Patients with Original Medicare may pay a monthly premium for a Medicare prescription drug plan provided by a private company. However, Medicare Advantage beneficiaries with plans that offer prescription coverage are usually required to obtain prescription drugs through the MA company. Premiums for Part D vary and are typically weighted so that higher-income beneficiaries pay more.
Patients with Original Medicare can purchase a Medicare Supplement policy that helps cover healthcare costs that Medicare Parts A and B don’t. That includes copays, coinsurances, deductibles, and—depending on the plan—healthcare services incurred while traveling abroad.
All Medicare benefits are determined by medical necessity, which means that clinicians must provide justifiably reasonable and necessary care according to evidence-based clinical standards of care. The definition of “reasonable and necessary” varies based on both National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs). Each provider is responsible for knowing the current NCDs and LCDs governing their practice. However, in most cases, the medical necessity of services is determined based on:
You can download the Medicare NCD Manual from CSM’s Internet-Only Manuals page and identify the LCDs associated with your particular geographic region by using the search tool found on the right side of the Medicare coverage database page.
To learn more about providing Medicare patients with services that are not medically necessary, click here.
In January 2013, the US District Court for the District of Vermont ordered CMS to clarify sections of its Medicare Benefit Policy Manual—which, as it turns out, does not require improvement as a condition of coverage. As part of this settlement, CMS also had to create and distribute new educational materials to correct long-standing and widespread misunderstandings about the Improvement Standard. While the settlement went into effect immediately for Medicare and Medicare Advantage plans, CMS had until January 2014 to comply with this order.
Here are some important things to note:
A rehab therapy clinic must accept Medicare to treat Medicare patients. Furthermore, per Chapter 15, Section 40.4 of the Medicare Benefit Policy Manual, physical and occupational therapists in private practice cannot “opt-out” of Medicare and therefore may not enter into private contracts with Medicare beneficiaries. In other words, rehab therapists who have a relationship with Medicare can’t accept cash payments from Medicare patients for medically necessary physical therapy services.
According to an article from the U.S. Census Bureau, every one of the estimated 73 million Baby Boomers will be 65 or older by 2023. That creates a potentially huge business opportunity for outpatient practices. That being said, there are successful outpatient clinics that are 100% cash-based. For more information on treating Medicare patients and the cash-pay world, understand what accepting Medicare assignment means.
If you’re interested in accepting Medicare Part B patients, use the below instructions to enroll online:
Medicare reimburses therapists when the documentation and claim forms accurately report the provision of medically necessary covered services. So, in addition to being legible and relevant, documentation must defend the services that therapists bill. Furthermore, documentation must comply with all applicable Medicare regulations and support included CPT codes. You can reference the latest Medicare documentation requirements published in 2022.
Please note that therapists should also follow any state or local laws regarding documentation and the professional guidelines of the American Physical Therapy Association (APTA) or the American Occupational Therapy Association—even if Medicare does not require it.
Please note that if a patient is receiving treatment in multiple disciplines (e.g., PT, OT, and/or SLP), then there must be a POC for each specialty, and each therapist must independently establish what impairment or dysfunction they are treating as well as the associated goals.
Furthermore, POCs require the dated signature of the referring licensed physician within 30 calendar days.
Regarding how specific physical therapy daily notes should be, the Coverage Manual, IOM Pub. 100-02, Chapter 15, §220.3. E. Treatment Note reads: "The purpose of these notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of the billing codes on the claim form. Documentation is required for every treatment day and every therapy service. The format shall not be dictated by the contractor and may vary depending on the practice of the responsible clinician and/or clinical setting. The Treatment Note is not required to document medical necessity or appropriateness of the ongoing therapy services. Descriptions of skilled interventions should be included in the plan or progress note and are allowed, but not required daily."
To learn more about defensible documentation for PTs, OTs, and SLPs, check out WebPT’s defensible documentation toolkit.
Medicare will not pay for physical therapy services unless the claim and documentation prove that a licensed physician has authorized the plan of care. Authorization from a licensed physician must include the physician’s full name, location, and contact phone number as well as their signature on the plan of care that explains the diagnosis and level of treatment intensity. This authorization certifies that only a physical therapist can offer the type of care the patient needs. If the patient can do exercises at home on their own at no cost, Medicare will not cover physical therapy services.
Dictation is compliant with Medicare’s guidelines as long as it occurs on the date of the patient visit and the therapist creates written documentation based on the dictation.
It’s important to note that some state practice acts have different referral requirements than Medicare—and providers must adhere to the strictest applicable rule. You can learn more about the direct access laws in your state with WebPT’s free download: The PT’s Guide to Direct Access Law in All 50 States.
As a result of direct access, in most cases, Medicare patients may receive physical therapy services without seeing a physician or obtaining a referral first. That means that a therapist may perform—and bill for—an evaluation to determine whether therapy is medically necessary for that patient without involving a physician or other approved non-physician provider (NPP). However, once a therapist determines that therapy is, in fact, necessary, then that patient must be under the care of a physician or NPP. As such, the therapist must obtain a signed POC certification within 30 days of a patient’s first visit. While Medicare doesn’t require patients to visit their physician, some physicians may require an office visit before signing a POC.
Medicare also doesn’t require that the plan of care be certified before treatment begins, which means therapists may begin treatment before obtaining certification. However, therapists should do so only if they are extremely confident they can secure the necessary certification within the month. Otherwise, the POC is considered “delayed,” meaning the provider must complete additional work to remain compliant.
Here are a few more tips to help ensure you get paid:
To learn more about Medicare’s certification requirements for therapy plans of care—including how developing relationships with providers can make the whole process easier—read Signature Move: Medicare's Certification Requirements for Therapy Plans of Care.
If you’re a WebPT Member, keep in mind that WebPT’s Plan of Care Report shows you which plans of care are still pending certification. It will also remind you to complete your re-certs before time runs out. Talk about a POC easy button.
Maintaining Medicare compliance is no easy feat. Read on to learn about the most asked-about Medicare regulations.
Physical therapists (PTs) are licensed providers in all states, and physical therapist assistants (PTAs) are licensed providers in the majority of states. Per the APTA, “as licensed providers, the state practice act governs supervision requirements. Some state practice acts mandate more stringent supervision standards than Medicare laws and regulations. In those cases, the physical therapist and physical therapist assistants must comply with their state practice act.”
In outpatient private practices, PTAs can provide physical therapy services, as long as they do so under the direct supervision of the physical therapist. CMS generally defines “direct supervision” as a situation in which the supervising private practice therapist is physically present in the office suite at the time the PTA performs the service. Understanding Medicare’s supervision levels is a must for clinic owners. For additional guidance on the use of PTAs in other settings, the APTA has published a resource for clinicians.
Per Medicare rule 42 C.F.R. §410.26(b)(1)-(7) and the CMS Medicare Benefit Policy Manual, Pub. 100-4, Ch. 15, §60.1 – §60.5, in order to bill for outpatient services provided by a PTA in a non-institutional setting, the claim must meet the following conditions:
Here are four tips to help you ensure your documentation demonstrates that you’ve met the aforementioned conditions:
In the 2019 final rule, CMS announced that beginning in 2022, Medicare will only reimburse 85% of the cost of outpatient physical therapy services provided in full or in part by physical therapist assistants (PTAs)—a policy was reaffirmed in the 2023 final rule. That means that if a PTA provides at least 10% of a given service, you must affix the CQ modifier to the claim—along with the GP therapy modifier—which will trigger Medicare to reduce its reimbursement rate. Providers began using the new modifier on January 1, 2020, and therapists started to see the reimbursement reduction on January 1, 2022.
Medicare will not reimburse for services provided by physical therapy techs, regardless of the level of supervision. Therapy techs may assist the professional therapist or therapist assistant in performing a specific therapy service; however, the tech can never provide the service.
Similar to what we mentioned above for techs, Medicare Part B will not pay for services provided by a therapy student, because students are not licensed providers. Thus, even if the therapist is in the treatment room with the student while the student is treating a patient, only the services provided by the therapist are billable. The exceptions to this rule, as well as the APTA’s recommended considerations with regard to billing for student-assisted services, can be found in the rules of supervision for rehab therapy techs, assistants, and students.
During the holiday season and summer vacation, private practices may need to hire substitutes, or contractors, to cover for their regularly employed therapists. But, when bringing in another therapist to treat patients, many practices face the “bill as” problem. To receive reimbursement from insurance companies, hired contractors must be fully credentialed with the same insurance companies whose beneficiaries the hiring practice treats.
One of the best ways to ensure this is to seek out contractors from qualified agencies with vetted insurance credentials. This may be a slightly more costly way of doing things than simply hiring a friend or associate, but to “bill as” correctly, you’re better off hiring a fully credentialed contractor. This is important for all insurance companies, especially Medicare. The contractor stepping in for an on-vacation therapist who treats Medicare patients must also be Medicare-credentialed.
Locum tenens means “placeholder” in Latin. It refers to a person who temporarily fulfills the duties of another. While physicians have the luxury of simply adding a Q6 modifier to the treatment claim to indicate that a replacement physician provided the services on a particular day, most PTs, OTs, and SLPs do not.
Let’s say you recently hired a new graduate or new employee, and they are still waiting to be credentialed. For Medicare, as long as the practice has sent in that therapist’s paperwork and that paperwork is pending CMS approval, the therapist can begin to treat patients. However, your practice must hold all claims for that new therapist (up to one year from the visit date of service, based on timely filing rules) until they receive credentialing approval. Medicare does not allow a co-signer on claims for non-Medicare credentialed contractors or employees. The uncredentialed therapist would need to reassign their individual Provider Transaction Access Number (PTAN) to your group, and you would then hold the claims until they receive approval.
In response to the COVID-19 pandemic, CMS introduced temporary telehealth services for rehab therapists on March 6, 2020—meaning that PTs, OTs, and SLPs can bill and be reimbursed for telehealth sessions with patients. However, the long-term future of Medicare telehealth services is somewhat in doubt; at present, telehealth privileges for rehab therapists are set to expire 151 days after the end of the public health emergency (PHE). With the PHE expiring on May 11, 2023, that means October 9, 2023, is the last day rehab therapists can be reimbursed for telehealth services. Making the issue even murkier is the fact that rehab therapists can continue to bill for telehealth through the end of CY 2023 — they just won’t be reimbursed by Medicare. For more on the state of Medicare telehealth services, check out this blog post.
A re-exam, re-evaluation, or reassessment (CPT code 97164) is completely different from a progress note, and therapists should not bill a 97164 for a progress note. In fact, you should only ever bill for a re-evaluation if one of the following situations applies:
Medicare helps pay for medically necessary outpatient physical, occupational, and speech-language therapy services when the licensed physician or therapist establishes a plan of care and the licensed physician periodically reviews the plan to see how the patient is progressing. Regarding copayment, the patient pays 20% of the Medicare-approved amounts. However, the patient must first pay an annual deductible ($226 in 2023) before Medicare pays its share.
Generally speaking, it’s illegal to waive copays for beneficiaries of federally funded programs such as Medicare and Medicaid. Medicare and Medicaid view waiving copays or deductibles as a misrepresentation of the true cost of your services. Although Medicare may permit waiving copays in very select circumstances, you should never assume that this will be the case. Read this blog post for greater detail on copayment collection for Medicare and third-party insurance beneficiaries.
As mentioned above, Medicare will allow for waivers of copayments or deductibles under very special circumstances. One such circumstance is financial hardship. However, waiving under the claim of financial hardship is easier said than done. First, a practice should rarely extend such waivers. Second, the practice must apply the same hardship criteria to all financial hardship cases. Practices should establish a financial hardship policy, which details the type of documentation a patient must supply (e.g., tax returns or unemployment compensation information) for the practice to consider the patient for financial hardship. Third, financial hardship is a last resort, and therapists should make all attempts to collect copayment or deductibles at the time of service. Ultimately, if a Medicare patient asks about waiving copayments or deductibles, the therapist should inform the patient that such a practice is illegal. Learn more about financial hardship and its importance in delivering access to care.
Co-treatment may be appropriate when therapists of different disciplines determine that they can better address a patient’s treatment goals if they provide their various individual treatments during a single session. Medicare has different rules for co-treatment based on coverage type and setting:
If a patient receives treatment from two practitioners in two different disciplines during a single session, each provider may bill for the entire session separately. Meredith Castin, PT, provides the following example: “If an OT and a PT co-treat from 10:30 AM to 11:30 AM, and the OT works on toileting strategies while the PT simultaneously addresses safe transfers, both clinicians could bill for that entire hour, provided they show proof of providing separate treatments with separate end goals.” Both providers must ensure their documentation reflects the necessity of co-treatment. For home care or care provided in a skilled nursing facility that bills under Part A, therapists can bill for co-treatment services as long as the plan of care and documentation support that decision. That said, the therapists must follow all policies regarding mode, modalities, and student supervision as well as all other federal, state, practice, and facility policies.
Therapists who practice in outpatient facilities, private practices, and skilled nursing facilities that bill under Medicare Part B cannot bill separately for the same or different services provided to the same patient at the same time. Essentially, therapists must limit total billing time to the exact length of the session, so a therapist of one discipline may bill for the entire service or co-treating therapists of different disciplines may divide the service units. In the case of a PT or OT co-treating with an SLP, ASHA has this to say: “Because SLPs usually bill treatment codes that represent a session (rather than an amount of time), and because Medicare has no published minimum/maximum session length, the SLP would bill for one untimed session.” The OT or PT would then bill “the timed treatment codes for the occupational or physical therapy.”
According to joint guidelines developed by the American Speech-Language-Hearing Association (ASHA), American Occupational Therapy Association (AOTA), and American Physical Therapy Association (APTA), for both Medicare Part A and B, therapists should only co-treat a patient when coordination between two disciplines benefits the patient. Therapists should never co-treat for “scheduling convenience.” As Castin explained, it’s also important to note that while “therapists often opt to co-treat for safety reasons. simply having a second person on hand to act as a contact guard (i.e., to prevent falls) is not enough to justify billing for a second therapist's services.”
Furthermore, documentation must clearly indicate the rationale for co-treatment and specify the goals each therapist will address through this method of intervention. Each therapist should document co-treatment sessions as such, specifically detailing which goals the team of therapists addressed and how the patient progresses. Lastly, therapists should limit therapy services performed during one treatment session to two disciplines.
Outpatient facilities and practices that provide both physical and occupational therapy may need to affix either modifier 59 or XP to claims when patients receive PT and OT services that form NCCI edit pairs on the same day.
According to Castin, while modifier XP would be appropriate if, say, “an OT takes over treatment in the middle of a PT session,” 59 would be appropriate if the payer doesn’t yet recognize X modifiers or there is another reason you need to “identify otherwise linked services that should, given the circumstances, be reimbursed separately.” For example, you would affix modifier 59 to the 97116 charge if, say, a PT provides gait training (97116) and an OT provides therapeutic activity (97530). Doing so notifies Medicare that the services were performed separately and distinctly from one another and thus should both be paid.
According to retired compliance expert Tom Ambury, concerns about holiday gift-giving often revolve around the Anti-Kickback Statute (AKS)—mostly because the AKS has “a broad definition of who is considered a referral source.” Essentially, the AKS prevents practitioners from providing any incentive designed to generate Medicare patient referrals, and anyone—healthcare practitioner or not—who refers a Medicare patient to your clinic is considered a referral source, according to the AKS. This means that giving gifts to patients can even be tricky, especially if they’ve referred patients to you and those patients happen to be Medicare beneficiaries.
To stay in the clear on all gift-giving endeavors, Tom recommends following the below Office of Inspector General (OIG) Guidelines for Gifts—and maintaining crystal clear documentation:
Many states have their own statutes, and it’s your responsibility to know the laws and guidelines that apply to the state in which you practice.
In 2011, CMS rolled out its multiple procedure payment reduction (MPPR) program, at which time Medicare stopped paying claims in full when a PT, OT, or SLP performed more than one related procedure on a patient during the same visit. As it stands now, therapists who perform more than one “always therapy” service on a patient during the same visit see a 50% reduction in practice expense (PE) billed to Medicare (the reduction was 20% from January 1, 2011, to March 31, 2013).
MPPR also extends across disciplines, which means that when two or more rehab therapists of different disciplines treat the same patient during the same date of service, CMS only pays the highest procedure value in full. CMS then reduces all subsequent procedures performed that day by half. According to the APTA, MPPR averages a 6 to 7% reduction in provider reimbursements (based on an average of 3.7 billed units per visit). That’s a lot.
So, why did CMS implement such a program? Part of the reason was to reduce the amount of money the Center was spending on rehab therapy prep time when more than one procedure was performed for the same patient on the same day. Remember that MPPR only affects practice expenses; however, each therapy service also includes work expenses and malpractice expenses. Thus, before MPPR, if more than one therapy service was billed at a time, CMS was paying more than once for pre and post-service activities—in addition to the actual service being provided.
That’s not to say the program is justified in its current form. Since the beginning, the APTA has asserted that MPPR is flawed—mostly because provider PE rates have already been reduced to avoid duplication. According to the APTA, “The fact that certain efficiencies exist when multiple therapy services are provided in a single session was explicitly taken into account when relative values were established for these codes. Therefore, an additional cut to the practice expense of therapy service codes is arbitrary and likely to restrict patient access to vital physical therapy services.” As a result, the APTA has advised providers to vary their payer mixes and review their contracts closely to ensure they know the terms they’re agreeing to.
If you’re an APTA member, you can use this updated Medicare reimbursement calculator to determine how MPPR will impact reimbursements for your clinic.
Therapists must adhere to all Medicare documentation and billing regulations. These regulations include the therapy threshold, the 8-minute rule, and MPPR. Failure to comply with Medicare regulations can result in penalties, denied reimbursements for provided services, and audits.
Here are the top three compliance red flags:
Furthermore, failure to do the following puts therapists at risk for Medicare audits:
Another documentation pitfall that could put you at risk? Modifying documentation following a denial or not supplying documentation when Medicare requests it.
On the billing side of things, avoid these risky behaviors:
Obtain a copy of Medicare’s Local and National Coverage Policies and familiarize yourself with the coverage criteria pertinent to your practice. Additionally, take advantage of any CEU opportunities regarding Medicare, and get acquainted with Medicare’s website to learn how to access key Medicare reference documents, like the program’s Claims Processing Manual. For more Medicare compliance training, check out Gawenda Seminars' webinars, blog, and resources.
In addition to educating yourself, it’s imperative that the rest of your practice’s staff understand and abide by Medicare’s regulations. We recommend conducting a self-audit and appointing at least one dedicated compliance officer within your practice who will implement a compliance plan. This plan should encourage therapists and staff to report any and all potential compliance issues, provide procedures for prompt and thorough investigation of possible misconduct, and detail appropriate responses to non-compliance scenarios. Compliance plans typically include the following:
CERT stands for Certified Error Rate Testing. According to the CMS website, CMS instituted the CERT program to produce a national Medicare fee-for-service (FFS) error rate compliant with the Improper Payments Information Act. “CERT randomly selects a sample of Medicare FFS claims, requests medical records from providers who submitted the claims, and reviews the claims and medical records for compliance with Medicare coverage, coding, and billing rules. The results of the reviews are published in an annual report.”
According to CMS, Targeted Probe and Educate (TPE) audits are “designed to help providers and suppliers reduce claim denials and appeals through one-on-one help.” As explained here, probe audits target:
Per CMS, some of the most common claim errors are:
That said, “if your claims are compliant with Medicare policy, [you] won't be chosen for TPE.” And if you are chosen, the process will look something like this:
According to an Oracle whitepaper, “The Health Information Technology for Economic and Clinical Health Act (HITECH) forces health care providers and their business associates to bring a sense of urgency to the security of protected health information (PHI). The act brings both pressures and incentives into play in its mandate to convert PHI to electronic health records (EHR), and puts teeth into the enforcement of the privacy and security rules of the Health Insurance Portability and Accountability Act (HIPAA).”
Part of the $787 billion American Recovery and Reinvestment Act (ARRA) of 2009, the HITECH Act aims to digitize US healthcare records, thus simplifying the exchange of health information, which will improve healthcare and increase operational efficiency (i.e., save money). To facilitate this digitization, the act mandates that eligible healthcare professionals switch from paper claims to electronic health record (EHR) systems. “The act provides $19.2 billion to promote the conversion, most of it going to Medicare and Medicaid reimbursement as incentives to make what the act refers to as ‘meaningful use’ (MU) of EHR, starting in 2011,” says Oracle. Essentially, to qualify for the incentive, these practitioners had to implement a certified electronic health record—that is, one that “offers the necessary technological capability, functionality, and security to help them meet the meaningful use criteria.”
By CMS standards, physical therapists, occupational therapists, and speech-language pathologists weren’t considered “eligible professionals” when it came to Meaningful Use. Thus, rehab therapists couldn’t earn the incentive associated with demonstrating meaningful use of an EMR—even if they implemented a system that had been certified for the MU program. Thus, rehab therapists needn’t concern themselves with any requirements related to MU. They should, however, concern themselves with acquiring a rehab therapy-specific EMR solution for their practice.
In 2016, CMS’s acting administrator, Andy Slavitt, announced the end of MU as we know it: “The Meaningful Use program as it has existed will now be effectively over and replaced with something better,” he said at the JP Morgan Annual Health Care Conference. Instead of continuing MU as a standalone program, CMS consolidated it—along with PQRS and the VM program—into the Merit-based Incentive Payment System (MIPS). While reporting began in 2017, physical therapists were not eligible to participate until 2019. "At its most basic level,” Slavitt said, “[MACRA] is a program that brings pay for value into the mainstream through something called the Merit-based Incentive Program, which compels us to measure [providers] on four categories: quality, cost, the use of technology, and practice improvement.”
Whereas MU required all eligible professionals to use an EHR that was Meaningful-Use certified, MIPS is taking the focus off of the technology itself and placing it on the outcomes clinicians can achieve through the use of technology.” With that in mind, while rehab therapists still don’t need an MU-certified software system, they absolutely do need to adopt a software platform that enables them to collect, monitor, and—most importantly—use meaningful outcomes in order to convey the effects of therapeutic intervention.
As of January 2019, physical therapists, occupational therapists, and speech-language pathologists are eligible providers under Medicare’s newest reporting program—the Merit-Based Incentive Payment System (MIPS)—which means some will be required to participate. However, given the low-volume threshold exclusion criteria, only about 10% of PTs will be required to do so (according to the APTA). MIPS participation in 2024 has changed quite a bit, so stay up-to-date on the newest requirements.
WebPT is a qualified registry for MIPS. So, if you are a WebPT Member and you purchase our MIPS package for 2023, then you’ll be able to document like normal in the EMR, and we’ll autofill the information into the MIPS measures, where applicable. You’ll then be asked to review the measure data to confirm that it’s correct. And you won’t be able to finalize your notes without it. After that, WebPT will store your MIPS data—and send it off to CMS at the end of the reporting year. For the Improvement Activities category, we’ll provide you with a link to the Improvement Activities attestation page where you can document your performance.
Just as we have this physical therapists’ guide to Medicare, we also have a guide to MIPS and participation requirements. If you need more reading material try these resources out as well:
At the end of each calendar year (CY), Medicare releases its final rule, at which point we learned the following:
Each year, we publish a free webinar and brief explainer on the final rule, so be sure to stay in the know.
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