Encore Keynote - August 2021

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- Encore Rehabilitation’s monthly publication, designed to give you updates on trends we are seeing in the SNF/LTC industry. - 

Eyes Out for Proposed and Final Rules


Eyes Out for Proposed and Final Rules


On Thursday, July 29th,  the Centers for Medicare & Medicaid Services (CMS) issued the final rule for the skilled nursing facility (SNF) prospective payment system (PPS) fiscal year (FY) 2022 update.

Here are the highlights:

  • The final rule provides a net market basket increase for SNFs of 1.2 percent beginning October 1, 2021.
  • The CMS net market basket update would increase Medicare SNF payments by approximately $411 million in FY 2022.
  •  CMS will not implement any PDPM payment model parity adjustment in FY 2022. Whether there will be any delay or phase in necessary will be revisited in next year’s FY 2023 proposed rule. 
Physician Fee Schedule Proposed Rule - Released July 13th, 2021
l.Conversion Factor - decreased from 34.89 to 33.58
ll.E/M Policy Provisions -therapy 1% decrease in work RVU and 1% decrease in PE RVU. The large revision due to E/M is not occurring.

lll. Outpatient Therapy Services - This is not a surprise that the 15% reduction for assistants remains in the Rule. If you recall, that reduction was in the bill Congress passed to end the yearly vote on the therapy cap. Congress has to act on this, not CMS.

Physician Fee Schedule Proposed Rule
CMS is preparing to implement the 15% reduction in payment for physical and occupational therapy services furnished in whole or in part by physical therapy assistants (PTAs) and occupational therapy assistants (OTAs), effective January 1, 2022.  CMS is doing this as part of implementing section 53107 of the Bipartisan Budget Act of 2018. The Proposed Rule notes that CMS previously established the CQ and CO modifiers to identify PTA and OTA services, respectively. CMS finalized a de minimis standard that considers a service furnished in whole or in part by a PTA or OTA when the PTA or OTA provides more than 10 percent of the service. 

CMS provides the following summary of the previously finalized de minimis standard for when the CQ/CO modifiers apply and when they do not, as follows:

  • Portions of a service furnished by the PTA/OTA independent of the physical therapist/occupational therapist, as applicable that do not exceed 10 percent of the total service (or 15-minute unit of a service), are not considered to be furnished in whole or in part by a PTA/OTA, so are not subject to the payment reduction.
  • Portions of a service that exceed 10 percent of the total service (or 15-minute unit of a service) when furnished by the PTA/OTA independent of the therapist must be reported with the CQ/CO modifier, alongside of the corresponding GP/GO therapy modifier; are considered to be furnished in whole or in part by a PTA/OTA, and are subject to thepayment reduction.
  • Portions of a service provided by the PTA/OTA together with the physical therapist/occupational therapist are considered for this purpose to be services provided by the therapist.
CMS also notes stakeholders raised concerns regarding certain cases where a provider may seek to limit care provided by PTAs/OTAs only 15-intervals to avoid applying the modifier to any minutes provided by the therapist. Stakeholders recommended CMS adopt an "8-minute rule" and other policy changes.   To address these concerns, CMS is proposing to modify its existing policy, specifically for these billing scenarios:
  • When only one unit of a timed therapy service remains to be billed (the majority of all billing scenarios)
  • The "two remaining unit" cases (described in the Proposed Rule)
Additionally, under this proposed modification, the CQ/CO modifier would not apply when the PT/OT furnishes 8 minutes or more, or both the PT/OT and the PTA/OTA furnish 8 minutes or more, of a timed service.  CMS is referring to this as the proposed "midpoint rule" policy, and Table 20 shows billing scenario examples where the "midpoint rule" applies.

CMS further states that the CQ/CO modifiers apply when the PTA/OTA provides all the minutes of a timed service, and to some services (as illustrated in Table 19) when the PTA/OTA and PT/OT each, CQ/CO modifiers also apply if the portion of an untimed code furnished by the PTA/OTA exceeds the de minimis standard. The CQ/CO modifiers do not apply when the PTA/OTA and the PT/OT furnish different services.  Time spent by the PT/OT and PTA/OTA providing services together is considered time spent by the PT/OT for purposes of applying the de minimis standard.   CMS is also proposing to modify its policy so the CQ/CO modifiers do not apply when the PT/OT provides enough minutes of the service on their own to bill for the last unit of a timed service (more minutes than the midpoint or 8 minutes of a 15-minute timed code) regardless of any additional minutes for the service provided by the PTA/OTA.

Finally, CMS provides the following information on implementing the therapy assistant reduction:  Beginning January 1, 2022, therapy services furnished in whole or in part by a PTA or OTA will be identified based on the inclusion by the billing therapy services provider (whether a therapist in private practice or therapy provider) of the CQ or CO modifier, respectively, on claim lines for therapy services, and the payment for those services will be adjusted as required by section 1834(v)(1) of the Act.  Per CMS' usual system update process, CMS plans to issue instructions in a change request to prepare its shared systems and Medicare Administrative Contractors (MACs) to pay the reduced amount for therapy services furnished in whole or in part by a PTA or OTA.  CMS will issue an MLN article once the change request is released after the CY 2022 PFS final rule is issued.

All therapy codes will NOT be added to telehealth permanently. Some are proposed to extend until 2023 but it appears some of the therapy codes will NOT—97150, 97530, 97542, 92526, 92508. CMS received several requests to permanently add various services to the Medicare telehealth services list effective for CY 2022. Unfortunately, CMS found that none of the received requests met their Category 1 or Category 2 criteria for a permanent addition to the Medicare telehealth services list, including codes for rehab therapy services.  However, CMS is proposing to retain all services, including rehab therapy services, added to the Medicare telehealth services list for the duration of the PHE on a Category 3 basis until the end of CY 2023.  According to the Proposed Rule, CMS proposes this, so there is a glide path to evaluate whether to add the services permanently to the telehealth list following the COVID-19 PHE.

Specifically, CMS received requests to add Therapy Procedures, CPT codes 97110, 97112, 97116, 97150, and 97530; Physical Therapy Evaluations, CPT codes 97161 – 97164; Therapy Personal Care services, CPT codes 97535, 97537, and 97542; and Therapy Tests and Measurements services, CPT codes 97750, 97755, and 97763, to the Medicare telehealth services list for CY 2022.

CMS determined that these services did not meet the Category 1 criteria for addition to the Medicare telehealth services because they are therapeutic and, in many instances, involve direct physical contact between the practitioner and the patient.

Furthermore, in assessing the evidence stakeholders supplied in support of adding these services to the Medicare telehealth services list on a Category 2 basis, CMS concluded stakeholders did not provide sufficient detail to determine whether all of the necessary elements of the service could be furnished remotely and whether the objective functional outcomes of ADL and IADL for the telehealth patients were similar to those of patients receiving the services in-person.  As such, CMS is not proposing to add these services to the Medicare telehealth services list.  However, CMS continues to encourage commenters to supply sufficient data for them to see all measurements/parameters performed to evaluate all outcomes.

Emergency Temporary Standard (ETS)
In July, Encore covered this topic in our monthly Rehab Roundtable webinar.

What to Expect:
  • Overview of the ETS
  • Requirements and timeline
  • Creating your COVID-19 plan
  • Employee training and education
  • Employer workplace agreements



Student Clinical Affiliation Program Is Back
Encore's Impact Award-winning Student Clinical Affiliation Program by the National Association of Rehabilitation Providers & Agencies (NARA). Clinical instructor educational and experiential development, student education and orientation, partnership with community school faculty, and employment opportunities within the Encore family are the foundation of this successful program.

If you would like to learn more about Encore's Student Clinical Affiliation Program, please get in touch with [email protected]

PEPPER Reports
Don't forget to reach out to your Regional Vice President to review and discuss your PEPPER Report.
To learn how to get your PEPPER Report


Need More Help?
Watch our Rehab Roundtable:
Adding PEPPER to Your Plate


Current Denial Trends
  • Missing authorization - documentation to support facility communication of payer and authorization requirements
  • Timely physician signature on certs and evaluations
  •  Diagnosis coded on the MDS is not supported in the documentation
  • Unsupported NTA scores
  • Coding of isolation not supported by documentation or diagnosis
  • ADL coding not supported
  • Coding of SOB when lying flat not supported
  • Therapy treatment diagnosis not carried over to the claim. Denied for LCD requirements
  • Managed care payer denials due to the changing NCCI edits for 59 modifiers


Hearing Loss in Older Adults
  • Hearing impairment is the third most chronic impairment among older people
  • 98% of older adults in LTC have hearing loss
  • Hearing loss in seniors increases risk for multiple comorbidities
    • Decreased ADL independence o  Increased hospitalization
    • 3x the risk for falls o  Increase in depression o  Greater chance for medication errors
  • Age-related hearing loss occurs when hair cells die naturally over time, typically occurs equally in both ears, and affects loss of high pitch rather than low pitch tones
  • Noise-induced hearing loss occurs when hair cells die   due to exposure to loud sounds for long periods of time, associated with changes to hearing, difficulty with clarity of sound rather than amplification, and usually occurs unilaterally
  • Hearing aides greatly improve hearing clarity, however, less than 30% of adults over the age of 70 haveused them.
  • Quote: “Blindness separates us from things, but deafness separates us from people” – Helen Keller
  • Impact of Hearing Loss
    • Safety – doorbell, fire alarms, running water, car horn, dog barking
    •  Leisure – TV, movies, radio, spiritual needs, family events
  • Hearing Handicap Inventory for the Elderly is a 10-question survey that looks at the emotional and social impact of hearing loss
  • Hearing assistance modifications: phone noise cancellation, LED flash or vibrating ring tones, caller ID, visual voicemail, text messaging, TV closed captioning
  • Environment: reduce background noise. The more impaired the hearing, the more important the background noise is reduced.
    • Bounce Soundwaves: hard floors, vaulted ceilings, cement/brick
    • Absorb Soundwaves: heavy curtains, bookshelves, houseplants, noise absorption panels
  • Techniques: maintain eye contact when communicating, good lighting, physical gestures, enunciate words, facial expressions (hard to do with face masks and face shields)
    • Face masks can make it harder to communicate
      • Masks muffle sound
      • Take away our ability to read lips and see facial expressions
      • Speaking with a mask can be hard for people with communication problems like aphasia or voice problems
      • Masks can be uncomfortable for people who wear hearing aids or cochlear implants
      • Masks with clear panels can help people communicate more easily
  • Therapy Impact in the SNF:  Speech Therapists and Occupational Therapists are trained to adapt environments, establish communication systems and interventions to improve and enhance client quality of life. OT’s and SLPs work with patients to assess communication skills and establish individualized treatment approaches.  OT’s educate the patient and staff on adapting the environment and approaches to functional daily activities. 
  • Results: improved quality of life, participation in leisure activities, improved successful communications with others



For more information:
[email protected]