The more things change, the more they stay the… just kidding, this is Medicare physical therapy billing we’re talking about.

The “Medicare Program; CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies…” better known as the Proposed Rule has finally been published. It is 1704 pages of loosely organized, obtuse, verbose, government-speak (by the way, DSHS, how about a table of contents? Your word processor will automatically build one for you).

I didn’t read the Mueller Report, but my assumption is it
was just as garbled. We are analyzing and reading every page of the proposed
rules, and there is still a lot to re-read, analyze, and understand. Here is a
summary of what we know about the proposed rule so far, followed by some of the
more important details:


  • The proposed rule didn’t bring to light a lot of unexpected changes to MIPS. In typical CMS fashion, they are slowly tightening the screws to make successful participation a little more difficult in 2019 than it was in 2018.
  • The proposed requirements for application of the new modifiers for services performed “in whole or in part” by PT or OT assistants are, (how can I say this delicately) crazy. If your organization has assistants, you should work on your plan to comply with these requirements right away.
  • Our old friend, the “KX modifier threshold” formerly known as the Therapy Cap is unchanged. The exact amount of the cap (sorry, “threshold”, difficult to tell the difference) is yet to be determined by the Medicare Economic Index.
  • UPDATE (12/17/19): The 2020 final rule calls for the targeted medical review threshold to stay the same at $3,000.


As stated above, no unexpected changes here. There is no
proposed change in the low volume threshold, MIPS eligibility, data collection,
or measure scoring. Here are some of the more important changes:

Minimum Performance Score

The minimum performance score for 2020 is expected to be
increased from 30 to 45 points. This means a score of 45 in 2020 would be the
minimum requirement to avoid a negative adjustment to your Medicare fee
schedule in 2022.

Performance Category Weights

It is clear that CMS is working to increase the weighting of
the Cost Category and decreasing the weighting of the Quality Category over
time. For physicians, the Cost Category is scheduled to be increased from 15%
of the weighting in 2019 to 20% in 2020, 25% in 2021, and 30% in 2022. It is
not clear whether CMS has any plans to include the Cost Category as part of the
performance weighting for PT and OT. We also don’t know if CMS has any plans to
include the Interoperability Category as part of the PT and OT performance

Data Completeness

On QCDR measures, the proposal for minimum data completeness
requirement is an increase from 60% to 70% of all eligible patients.

Preference for Outcomes Measures

CMS is continuing to emphasize that there is a preference for Outcomes Measures over Performance Based Measures. (Those of you who remember the old PQRS program know that it was largely compromised of performance measures, like Fall Risk, Falls Plan of Care, BMI, etc.)

Feeling lost in a fog of MIPS terminology? Download our free MIPS glossary to gain a better understanding of its common and not so common terms.

Download Glossary

Expanding the Scope of QCDRs

Currently, QCDRs are not required to support multiple
performance categories. Beginning in 2021, QCDRs and Qualified Registries will
be required to support multiple performance categories and QCDRs will have
additional requirements to “foster improvement in the quality of care”.

There is a lot more to understand about MIPS changes, but it
is evident that MIPS is a program that is here to stay and successful
participation in MIPS will be critical for Medicare providers.

“Harmonizing” Measures

QCDRs will be expected to eliminate duplication of measures.
If similar measures exist in another QCDR, CMS may require that the measures
are “harmonized” to eliminate duplicative measures.

Assistant Modifiers

We knew the new Assistant Modifiers would be required in 2020, and that there would be an adjustment to the Medicare fee schedule for services performed “in whole or in part” by assistants beginning in 2022. What we didn’t know is how CMS was planning to define what constituted services performed “in whole or in part” by assistants.

Unfortunately, CMS has given us their answer, and it is all
based on an insane, arcane, complex time basis:

First the simple scenario. When a PTA or OTA performs all of
a service (as defined by a CPT code) in a given visit, all services performed
by the PTA would require a CQ modifier in addition to the GP profession type
modifier indicating physical therapy services. Services performed by an OTA
would require a CO modifier in addition to the GO profession type modifier
indicating occupational therapy services. So far, so good.

It gets complex when talking about services performed partly
by an assistant and partly by their supervising therapist during the same
visit. In that scenario, the CQ or CO modifier is to be applied for those
services (or CPT codes) when the time that the assistant is greater than 10% of
the total time spent providing the service.

To increase the level of fun, CMS is proposing two different
methods for determining this 10% standard:

  • Method 1: Divide the total minutes of assistant
    provided service by the total minutes spent providing the service and round to
    the nearest whole number. If the number is 11%, then the assistant modifier is
    required for the service.
  • Method 2: Divide the total time spent providing
    the service by 10, round to the nearest whole number, and add 1 minute to
    identify the number of minutes of service that are required to exceed the 10%
    standard, then apply the modifier as appropriate.

Quick Quiz

If a PT and a PT Assistant spent a total of 45 minutes
supervising therapeutic exercise for the same patient, how many minutes would
the PT Assistant have to spend on the service before applying the CQ modifier
on the claim using Method 1? How about Method 2?

Please email me at
with your answer. The first correct answer (or at least the answer that I
believe to be correct) wins either an all expense paid trip to Bermuda, or a
$25 Starbucks Card, depending on my departmental budget.

Stay Tuned!

We are continuing to re-read, analyze, and ask questions, and we will be offering webinars to explain the requirements. Let’s hope for no last minute surprises in the final rule!

Edit: In a previous version, we stated that the payment reduction for PTAs and OTAs begins in 2021. This was incorrect. The right year is 2022 and has been changed above. Thanks to Tracy at AGM Physical Therapy for keeping us on our toes.


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