2022 fee schedule and medicare final rule

2022 Medicare Final Ruling and Physician Fee Schedule

CMS Releases the 2022 Fee Schedule and Final Rule

Earlier this month, CMS published the final 2022 fee schedule and complete final rule for Medicare payment policies. Chad Madden, Breakthrough cofounder, teamed up with Mary Daulong, President and CEO at Business & Clinical Management Services (BCMS) to discuss the new rules shortly after they were finalized, on a Live Q&A with hundreds of private practice owners and therapists. 

This article summarizes a number of questions and answers that came up around the fee schedules and new 2022 Medicare rules.

If you’re in the process of planning for the impacts of the 2022 Medicare cuts, check out Breakthrough’s 2022 Planning Tool for Private Practice Owners. As private practice owners, it’s important to regularly assess the financial health of your practice and identify strategies to increase top-line revenue. Use this tool in your annual planning process to develop strategies that will boost profitability in spite of declining reimbursements. 


Q: What are the key changes in the 2o22 fee schedule and final rule?

A: Here’s the big picture:

  • PTs will see ~3.7% reduction in payment and OTs will see ~3.9% reduction in payment.
  • PTAs using the CQ modifier and OTAs using the CO modifier will see a 15% payment reduction
  • PTAs and OTAs may be virtually supervised using A/V communications until 2023.
  • Remote Therapeutic Monitoring (RTM) codes can be billed by physical & occupational therapists, nurses, etc.
  • Therapy KX Modifier Threshold = $2,150 PT/SLP & $2,150 OT.
  • Medical Review Threshold = $,3000. Hitting the threshold does not provoke an audit automatically – they are looking for aberrant billing behavior.
  • MIPS changes: Multiple adjustments to the program, but they re-established Q 154 Falls Assessment.


Q: What is the order of payment reductions on a claim with the CQ or CO modifier? 

A: For the therapy services to which the 15% reduction applies, payment will be made at 85% of Medicare’s (80% payment). This is based on the lesser of the actual charge or applicable fee schedule amount for claims with a CQ or CO modifier. The beneficiary’s co-insurance is deducted after the application of the MPPR to the PE Payment for all “always therapy” codes. The 2% sequestration reduction is always applied last.


Q: Regarding Remote Therapeutic Monitoring…can patients self-report their medical data? What about non-physiological data? 

A: Yes, patients can log their own data into RTM portals using a medical device. Patients can report non-physiological data such as their home program compliance, pain level, medication, etc.


Q: Do we still have the direct supervision rule where a PT has to be present in an outpatient private setting? 

A: The physical therapist is required to be onsite with the PTA as part of the Direct Supervision rule in a private practice under Medicare. During the pandemic, therapists were granted a form of “general supervision” which allows audio visual supervision as an alternative to direct supervision. General supervision is expiring at the end of 2022, meaning the A/V supervision option will be eliminated and therapists in private practice will be required to utilize “direct supervision” i.e., on-site. Changing this rule would require legislative action. 

Follow and support the bill for PTA/OTA General Supervision, called the HR 5536 “SMART” ACT. Write and talk to your congressman about it. It makes no sense for therapists in private practice to be held to the direct supervision requirement, while other comparable settings have general supervision prerogatives.

Q: How many evaluations can we bill in a year? What length of time? ex: every 30 days, 60 days etc. 

A: There are multiple considerations to keep in mind, including:

  • What does your Practice Act state regarding the therapist’s responsibility/requirement for evaluating new patients and/or conditions? If it stipulates specific requirements, those must be followed regardless of payment for services.
  • An evaluation or reevaluation is required by Medicare if the patient presents with new conditions or diagnoses. These can impact the Plan of Care Goals and Treatment Plan and should be performed and billed accordingly. Medicare typically expects a change/modification in an existing Plan of Care if an Evaluation or Reevaluation is billed. Of course, recertification of the new Plan of Care is also required.


Q: We’ve noticed that the G0283 CPT code is being denied as not medically necessary. Is this a trend for the future? Is there some other way we should be billing this code? 

A: The G0283 modifier is not a bundled code, so that is not the problem. Have you affixed the appropriate other modifiers i.e., GP or KX, if applicable?

Some Medicare Administrative Contractors (MACs) have Local Coverage Determinations (LCDs) that limit the frequency of certain modalities. Visit your MAC’s website to see if there is an LCD for Physical Therapy/Therapy Services.

There is no other way to bill G0283, and doing so could constitute a False Claims Act violation. Always bill according to the CPT code’s definition.


Q: If the owner/PT signs all notes, will there be any reductions for PTA’s?

A: An owner or other therapist cannot circumvent the intent of this rule by signing notes for services performed by a PTA/OTA. If the owner is not the person providing the service, that could become a False Claims Act violation. There is CQ or CO exemption by cosigning for services provided by an assistant. 

If the PTA treats the patient, you must comply with the regulation that specifies when the CQ or CO modifiers must be used. There are a number of scenarios that are included in the Medicare Physician Fee Schedule Proposed Rule (July 2021) which you can reference. 


Q: What is Locum Tenens? 

A: Locum Tenens (Fee-for-Time) is the use of a substitute provider to cover for an enrolled provider in his or her absence in specific situations. There is an important bill on the Hill entitled Nationwide PT/OT Access to Locum Tenens, S2612 & HB1611, which we encourage you to support. 

Access to Locum Tenens would give therapists the ability to be in compliance with Medicare rules in situations where they need someone to cover for them. Just like any other type of provider, therapists run into situations where they have emergencies, personal matters, or are short staffed, and have to get another therapist to provide care to active patients. Today, therapists don’t have that prerogative. If you’re using a PRN therapist who is not enrolled and you choose to bill under someone’s number who is not the providing therapist, you have a potential False Claims Act violation.

If this bill goes through, therapists would be able to utilize another therapist who is not enrolled in Medicare. The clinic would bill under the therapist being replaced and would pay the locum tenens therapist for the time or per visit. If you’re using a PRN therapist who is not enrolled and you choose to bill under someone’s number who is not the providing therapist, you have a potential False Claims Act violation.


Q: If the Access to Locum Tenens bill goes through, will it be available for Medicaid as well?

A: We don’t know. Medicaid has state policies, and those policies have to be dealt with on the state level. Policies can vary from state to state and that may be one area that may not follow Medicare coverage policies.


Q: What is the status of Sequestration going into 2022? Will the sequestration be reinstated?

A: Sequestration is a 2% reduction in payment that has been mandated since 2013. It was suspended during the pandemic, but yes, it will eventually be reinstated. It is legislatively required and would take congressional action before 2022 to be halted. 


Q: What if you choose to go non-par w/ Medicare and/or refuse to see Medicare patients? 

A: You can choose non-participation, but you still must be enrolled in Medicare. Therapists do not have the prerogative to “Opt-Out” of Medicare. You can either enroll or not enroll. If you are enrolled, you can participate by accepting assignment of benefits. If you choose not to participate, you are choosing not to accept assignment, but you still must be enrolled and file claims for the patient. Under non-participation enrollment, you may bill up to the limiting charge, which is 15% more than Medicare. In order for that to work, you have to be prepared to collect cash at the time of service. 

Those therapists with cash-based practices typically have a population of patients that are willing and able to pay cash upfront. In the non-participation situation, the patient will get reimbursed at 95% of the Medicare allowable within a few weeks of claim submission by the clinic. Remember, they will also be paying up to the additional 15% allowable upcharge. 

The success potential of choosing to be a non-participating provider is slim if your practice serves patients on a fixed or limited budget. The result of electing this payment strategy will limit patient access due to financial constraints. 


Q: Is there any update from Medicare and/or other commercial or federal payers regarding covering telehealth (or virtual visits) for PT?  

A: Today, telehealth services provided by therapists are allowed through the end of the year in which the year the pandemic is declared over. Since the Public Health Emergency was extended on October 15th, telehealth services by therapists will be permitted through 2022. If there is no congressional action and the pandemic is declared over in 2022, therapists will no longer be able to provide services via telehealth in 2023. We are not statutorily listed as telehealth providers. 


Q: Does the Emergency Regulation Requiring COVID-19 Vaccination for Health Care Workers apply to outpatient clinic employees, regardless of # of Employees? If so, does it apply to ALL employees, regardless of contact with patients?

A: What we know right now is that OSHA’s COVID-19 Vaccination Emergency Temporary Standard took effect upon its publication in the Federal Register (November 4, 2021). Employers must comply with most requirements within 30 days of the publication and with testing requirements within 60 days of publication. Employees will have the option of vaccination or weekly testing. There are medical, religious and other exceptions. Employer fines for non-compliance are massive.


Unsure how to plan for 2022 given the looming reimbursement cuts?

Download the 2022 Planning Tool for Private Practice Owners.

breakthrough employees Jordana Knoblauch

Breakthrough Employee Spotlight: Jordana Knoblauch

Get to Know Breakthrough Employees

Meet Jordana Knoblauch, our Strategic Account Manager and Queen of Questions (she always asks the best ones).

Q: What is your job at Breakthrough? 

A: I’m the Strategic Account Manager for existing customers who want to explore new products and opportunities, such as beta programs and expansion to other locations. I help facilitate those conversations. I also work to identify which customers are high adopters and which ones are lower. To help turn low adopters into more active users, I share best practices so they can get a high return on investment. 

Q: Tell us about you and your background. 

A: I’ve been on the Breakthrough Team for two and a half years. I’m from Canada and have a background in Finance and Marketing. Out of university, I worked at a SAAS company in sales, and quickly became a sales manager overseeing a sales team. This was a fantastic experience, but one thing I missed in that role was having a long-term relationship with customers. I would build up great rapport with a customer during the sales process, and then have to pass them off to the customer success team. It made me realize that customer success might be a better fit for me, because it would allow me to build long-term relationships. 

Breakthrough was my first experience with customer success. I loved it! Now, the company has empowered me to grow into a role where I am both supporting customers and identifying expansion opportunities for them. It’s the perfect mix of what I’m good at and what I enjoy. 

Q: What’s different about working at Breakthrough compared to previous employers? 

A: Its leadership team. The amount they care for the employees and the level to which they involve us in the strategic vision of where we’re going is unlike anything I’ve experienced. They ask for our opinions and involve us in the process of designing and implementing the company’s strategic initiatives. There’s a lot of business transparency. They’re upfront with us about where we’re missing the mark and where we’re killing it. 

Another thing is the flexibility and trust the company offers the Breakthrough team. You can really design your schedule in a way that works best for you so you can have work-life balance. As long as you’re hitting your metrics and getting your work done, leadership across the board wants you to be happy and live the life that works for you- whether you want to work remote from Turkey or work as a night owl!

Q: What are the most exciting trends you’re seeing in the field of healthcare SAAS and marketing? 

A: The most exciting trend I see is private practices becoming less reliant on physician referrals. Working with customers, they’re typically highly reliant on physician referrals when they start with us. Like 90% of their business is from referrals. A year or two into working with us, they start to say, “Wow, I’m now only 30% reliant on physician referrals.” They feel like their destiny is within their control rather than at the beck and call of someone else. Plus, we enable them to focus on their speciality and become known as a local ACE (Authority, Celebrity, & Expert) for that niche. 

We have a dialed-in system of how practices can become profitable in the first year, and it works. I’ve had multiple practices launch new clinics and they’re profitable in the first year. That’s almost unheard of without our marketing.  

Q: Any advice for younger professionals in this space? 

A: Some advice for students of all ages – get involved in your local community. This helps you build great communication, networking and leadership skills. For example, I was a student leader for 3 out of the 5 years that I was at university. I learned a lot of my communication and leadership skills there that I apply to my career today. 

Q: What would you want our customers and partners to know about Breakthrough? 

A: We’re more than just workshops. Breakthrough brings a LOT of value to practices you might not think of, such as discounted rates with other vendors we have partnerships with. Or access to our community where you can learn the good, the bad, and the ugly so you don’t have to make the same mistakes as others.

We create processes and standardization within your clinic so you can scale and have a consistent plan to execute against, and you’re not just shooting from the hip. And we help you utilize your biggest asset, which is your past patient list, something a lot of people don’t leverage. When we help customers tap into this list, there’s an immediate value we bring that’s usually a “WOW!” moment. 

Most importantly, when it comes to our customers, they should know the engagement for us is not just a business transaction. They’re true partners in helping us “flip the pyramid” of healthcare. The Breakthrough team truly cares and wants to help them overcome anything they’re struggling with so they can get big wins.