4 keys to maximize profits and patient commitment

In our most recent episode of the “Grow Your Practice” podcast, we had the pleasure of hosting Dr. Sterling Carter. As a multifaceted entrepreneur, motivational speaker, and seasoned physical therapist with a 25-year military background, Dr. Carter shared 4 keys to maximizing profits and patient commitment for physical therapists looking to elevate their practices. His insights include tactics for negotiating with insurance companies and ensuring patient accountability.

The 4 Keys to Maximizing Profits and Patient Commitment

1 – Successful Negotiating with Insurance Companies

Dr. Carter has successfully renegotiated reimbursement rates with insurance providers, addressing a critical financial pressure point for many practices. He recommends several effective strategies:

  • Preparation and Research: Understand and articulate the value your practice provides.
  • Structured Communication: Draft clear and professional communications to outline your case.
  • Persistence: Follow up persistently, as it often leads to success.

2 – Ensuring Patient Accountability

The physical therapy entrepreneur employs several methods to enhance patient commitment and treatment outcomes:

  • Educational Workshops: He conducts free sessions that educate patients about their conditions and the benefits of physical therapy.
  • Structured Plans of Care: He clearly outlines treatment phases to help patients understand their journey.
  • Patient Contracts: Patients sign a form committing to their treatment plan and attendance, significantly improving adherence.

3 – Expanding Practice Services

Understanding the value of upselling, Carter has broadened his practice’s offerings by adding specialized services such as dry needling, laser therapy, and shockwave therapy. These services not only enhance patient care but also boost revenue, helping to mitigate the impact of low insurance reimbursements.

4 – Building a Brand and Community Presence

As an entrepreneur, Dr. Carter underscores the importance of a strong brand and active community engagement. By hosting educational workshops and effectively using digital marketing, his practice builds trust and increases visibility. These efforts are crucial for attracting and retaining patients in a competitive market.


Dr. Carter combines business acumen with a deep understanding of physical therapy’s clinical aspects. By adopting his strategies, therapists can enhance both the operational and financial health of their practices. We’re so excited that he was able to find success in growing his practice with our help at Breakthrough.

On July 18, Learn How to Increase Your Revenue Per Visit

Dr. Carter is speaking at Breakthrough’s upcoming Rev/Visit Virtual Summit. Click here to learn more and register for this free event.

How to increase your revenue per visit with Dr. Sterling Carter

Increase Your Profit By $10,000 or More

Remember, growing your practice is not just about adding more patients but optimizing every aspect of your operation, from insurance negotiations to patient accountability, marketing, and community involvement. If you’re ready to increase your profit margins by $10K guaranteed, apply for Profitability Under Pressure today. You’ll learn even more keys to increasing profit margins, connect with like-minded owners, and achieve financial stability and growth.


As the President and CEO of BCMS, Mary Daulong has dedicated more than 30 years to helping physical therapists make sense of the complexities of billing and compliance. Physical therapy billing and compliance is anything but simple. But it’s incredibly important. Especially today, with reimbursement rates declining, costs increasing, and profit margins slimming.

In a recent Breakthrough Patient Demand Summit presentation, Mary Daulong shared important compliance strategies. Implementing these best practices can prevent unnecessary financial loss and increase profit.

3 Compliance Strategies BCMS Recommends for Increased Profit

Read on to discover three key compliance strategies for boosting profitability.

1. Changing Payment Methodology

Navigating Medicare’s payment system can be challenging, but it’s important to have a good understanding of your options in order to maximize your reimbursement rate.

Daulong advises changing your enrollment status from “participating” to “non-participating” supplier between mid-November and December. This lets you collect more payments.

Specifically, you can collect more total allowable money as a non-participating provider. In addition, you can collect payment directly from the beneficiary at the time of service, similar to cash-based practices. This may require some consideration, as collecting cash from patients can be difficult. However, there’s an incentive to make this change—you can collect 115% of Medicare’s normal allowable fee for physical therapy services as a non-participating provider.

The BCMS CEO says that implementing this approach can significantly improve your cash flow because you no longer have to wait for payment. Instead, you receive payment at the time of service.

It’s important to understand that Medicare will pay the patient directly instead of reimbursing you since you’ve already collected payment. Also, Medicare will pay the patient 75% instead of the usual 80% of the allowable fee schedule. So, collecting from the patient is crucial to make this system work effectively.

As you can see, there are some risks involved in this change. Medicare reduces the fee schedule for patients by 5%, which means they’ll have to pay more. Additionally, Medicare pays the patient directly for their co-share. If you’re not willing to collect payment at the time of service, then don’t switch to a non-participating status.

physical therapist adjusting patient's shoulder
Source: Shutterstock

2. Evaluate Your Unit Counting Methodology

Medicare’s 8-minute rule often stumps physical therapists. It determines how units are counted and reimbursed for service. The BCMS CEO breaks down how it’s calculated and how you can use it to increase revenue:

  • 8 to 22 minutes: 1 unit
  • 23 to 37 minutes: 2 units
  • 38 to 52 minutes: 3 units
  • 53 to 67 minutes: 4 units
  • Each additional 15 minutes: add 1 unit

However, the American Medical Association (AMA) has a different rule: anything over 50% of the total 15 minutes per unit can be billed as one unit.

Whether you use the Medicare or AMA methodology, you must utilize the most up-to-date version of the Current Procedural Terminology (CPT) codes (with a few exceptions). You should also determine which methodology your payer follows. Do a thorough review of their coverage policies. If Medicare is mentioned but there’s no explicit information, it’s generally safe to assume they adhere to the 8-minute rule.

BCMS Examples: How the Billing Methodologies Differ

The key difference between the Medicare and AMA methodologies is how minutes are counted. Medicare calculates the total minutes and then determines the number of units. However, AMA counts minutes per CPT code and expects at least 50% of the 15-minute allowance for each unit. To receive two units of the same CPT code under AMA, you must reach the full 15 minutes plus an additional eight minutes.

BCMS illustrates some examples in this presentation. We’ll look at two of them.

In the first example, AMA would allow three units based on a total of 24 minutes, while Medicare would generate two units because the total minutes do not meet the required threshold.

BCMS billing presentation example A
Source: BCMS

In the next example, AMA would only allow one unit because the total minutes don’t meet the minimum requirement. But Medicare would provide two units based on the total minutes.

BCMS billing presentation example B
Source: BCMS

You must understand the differences between the Medicare and AMA methodologies to bill units accurately and maximize your revenue. Carefully analyze the minutes for each CPT code and ensure compliance with the specific requirements of your payer to optimize your billing process.

3. Utilize ICD-10 Codes To Tell the Story on the Claim

Another key to increasing your revenue is to utilize ICD-10 codes (International Classification of Diseases). According to the BCMS CEO, the right codes can help convey the complexity of the patient’s condition.

Suppose you have a patient with a total hip replacement who also presents with other significant comorbidities. In this case, it’s crucial to include this information, supported by the referral or medical provider’s documentation. When you add the relevant impairment diagnoses to the claim, it illustrates the intricate nature of the case. The reader then understands the complexity involved.

It’s also essential to progress beyond basic exercises and range of motion activities for your patient to help them achieve functional independence. Diversify the exercises throughout the entire episode of care.

When you incorporate therapeutic activities, utilize action words such as bending, lifting, and pivoting. These activities indicate the involvement of multiple joints and muscle groups, providing a challenging workout for the body.

By accurately documenting the complexity of a patient’s condition and incorporating varied therapeutic activities, you can effectively convey the challenges and progress achieved throughout the treatment. This comprehensive approach ensures your procedure encompasses the multifaceted nature of the patient’s needs and can be billed higher.

physical therapist with senior testing techniques
Source: Shutterstock

4. Avoid Redundant Coding: Use Progressive Coding

Many practitioners resort to redundant or convenient coding practices, which can be problematic. The BCMS CEO says compliance with Medicare guidelines and HIPAA regulations is essential and requires utilizing the appropriate codes and their definitions.

Use progressive coding instead, where patients start with basic interventions and gradually progress to more advanced activities that promote independence and functional improvement. Make sure your coding aligns with the specific activities performed and their intended purpose.

Inaccurate coding can have financial consequences for your practice. Most notably, you won’t receive the full entitled amount. It may be small, but it can cost you thousands of dollars in lost revenue over time. So, always ensure accurate coding protocol to keep your practice compliant and protected.

Don’t Stop at These BCMS Tips—Increase Revenue With Breakthrough

To manage your revenue cycle efficiently, you must code and document every procedure to ensure appropriate reimbursement. The goal is to get paid 100% of what’s allowed quickly and efficiently.

Breakthrough’s program: Profitability Under Pressure: A Program Exclusively for Physical Therapy Practice Owners, provides eight weekly group calls, access to online resources, and the ability to attend in-person events to support you in some of the daily challenges you face within your practice.

Click here to learn more and apply for Profitability Under Pressure.

Successfully negotiating physical therapy reimbursement rates

How One Practice Increased Physical Therapy Reimbursement Rates by 15%

Private practice owners have been hit with a double blow over the past few years. Inflation has driven a significant increase in operational costs. At the same time, the physical therapy industry as a whole has experienced reimbursement cuts:

If you think there’s nothing you can do about physical therapy reimbursement rates, you may be surprised.

While many practices have seen profit margins decrease, Kinetix Physical Therapy in Gainesville, Florida has almost tripled revenue in the past six years. One of the key components of their success has been their ability to successfully renegotiate with insurance providers. This has allowed them to secure better reimbursement rates.

The practice has been able to increase PT reimbursement rates by an average of 15% over the last couple of years.

At Breakthrough’s recent Patient Demand Summit, Tony Cere, Co-Owner at Kinetix PT, shared his exact experience with renegotiating reimbursement rates. You can watch that session or continue reading for the key takeaways.

Tony Cere, Co-Owner of Kinetix PT, shares his experience renegotiating physical therapy reimbursement rates

Growth Oriented Practice Seeks to Increase Physical Therapy Reimbursement Rates

Tony and Melissa Cere opened Kinetix Physical Therapy in 2008. At the end of 2016, Kinetix PT partnered with Breakthrough to help them compete locally and grow. They attribute great gains in their business to this partnership.

In just two years, Kinetix PT’s revenue doubled from $950,000 to $1.8 million and expanded the size of their clinic. And that was just the beginning.

In 2022, they grew to $2.8 million in revenue and are now opening another clinic. This will allow them to double their current practice size.

Working on the Business, Not In It

As part of the Breakthrough community, Tony learned the importance of focusing his time on his responsibilities as a business owner. This meant backing out as a full-time clinician. This transition proved to be a real game-changer. As a result, he is able to identify revenue growth opportunities. One of the most valuable activities he is now able to spend time on is negotiating better physical therapy reimbursement rates with insurance providers.

In 2020, Kinetix PT—like everyone else—saw expenses increase and reimbursements continue to decrease. There seemed to be little light at the end of the tunnel. Their saving grace? At the time, it was cash-based services. By adding cash-based services such as Lightforce lasers, foot levelers, diagnostic testing, and MSK ultrasound, Kinetix was able to provide significant buffer to its profit margin. Last year, Kinetix PT brought in around $340,000 in cash-based revenue.

However, as a physical therapy practice, the Ceres felt the practice should be profitable without relying on cash-based services. These added services should only cushion their already-healthy revenue. So they took a closer look at their payer mix and average cost per visit.

A Shocking Revelation About Physical Therapy Reimbursement Rates

When he dove into the numbers, Tony realized they were actually losing money by seeing patients with certain insurance providers. It was time to decide to either drop those payers or renegotiate their contracts.

The Process of Negotiating Physical Therapy Reimbursement Rates

The Ceres decided they would try contract negotiations first. The process was challenging and required significant commitment and perseverance. But Tony says it’s one of the most valuable things he’s done for the practice. It’s helped to secure healthy physical therapy reimbursement rates. Not only for 2023, but for years to come.

Tony started negotiations with one of their biggest payers. It made up 35–40% of their patient population. The process entailed multiple rounds of trying to find (and then reach) the right contact person within the insurance company.

Tony set up detailed presentations stating their case. He showed the significant inconsistencies between reimbursements for their private physical therapy practice and other institutions such as hospitals. The report also included figures explaining how some patient visits were actually draining practice finances due to the low reimbursement rate. He highlighted cost increases over the past few years and the lack of reimbursement adjustments to compensate.

Frustrated with declining physical therapy reimbursement rates? Discover effective strategies for negotiating reimbursement rates.

The Results of Contract Negotiations

Tony conducted continuous follow-ups and escalated their request to more senior staff members at the company to get noticed. Eventually, it worked. He negotiated a 10% increase annually in 2021, 2022, and 2023. This totaled a 30% increase over 3 years and raised their per-visit reimbursement with that payer from $62 to $83. Factoring in the volume of patients over 12 months, this improvement has had a noteworthy impact on their revenue.

Tony followed the same procedures with other network partners. He achieved some reimbursement increases from these as well. Results have been mixed. But even a $5 reimbursement increase per visit adds up to a great improvement over 12 months.

9 Steps for Renegotiating Your Physical Therapy Reimbursement Rates

Private PT practice owners are all facing the the same challenges Tony and Melissa have tackled over the past few years.

But most don’t realize they can do something about it.

Tony and Melissa’s perseverance and strategic approach shows us there’s hope. Try applying these best practices to achieve the same success negotiating with insurance providers.

1. Identify the payer(s) you want to negotiate with

Prioritize negotiations with the insurers that have the highest patient volume and lowest reimbursement rates. Payment levels can vary significantly amongst different providers.

2. Decide what rate you would need

Look at your revenue per visit and cost per visit. Decide how much more revenue per visit you would need for a healthy profit margin. For instance, Tony aims to make 20% revenue on top of the cost to see the patient.

3. Find the right person to talk to.

Tony recommends talking to the provider relations department of your insurance carrier. Aim high and get in touch with the most senior-level contacts you can.

4. Be persistent in your outreach.

This process takes time. You may not get a response right away. They may even say no. But keep going. Contact them by phone and email. Keep following up regularly until you reach someone who is willing to talk. If needed, set up a follow-up schedule for yourself. Once you have success with one company, it can give you further motivation and hope for others.

5. Gather your data.

Once you get a meeting with the insurance carrier, ensure you have all the necessary data. Use figures to highlight that current rates are non-viable for a private physical therapy practice to provide high-quality care. Your numbers should include PT total compensation costs per unit, per patient, and total per visit costs. Organize it clearly and concisely in a graphical format (such as PowerPoint) for maximum impact.

6. Write a letter to your contact requesting a rate increase.

Include the following steps, 7 through 9, in your letter.

7. Make it clear how you are a benefit to your community.

Show how you excel above your competitors in the area. Use patient reviews and testimonials if available. Emphasize your differentiators and high success rates. If your practice is great at physical therapy marketing and attracting patients, highlight that as a differentiator.

8. Explain how your business costs have increased.

Support this with documentation. Show how the current physical therapy reimbursement rates you’re receiving from them are causing financial losses for your practice. If you haven’t received a reimbursement increase from this payer in a long time or ever, be sure to note this.

9. Describe how financial losses negatively impact your patients.

Reiterate that a fair and sustainable reimbursement structure is crucial for deliver high-quality care to the insurance company’s members. Express your commitment to providing exceptional care.

Perseverance is Key

Many practice owners believe their practice is too small to negotiate with payers. But in fact, payers can benefit by working with you. Even with an increase in your rate, they’ll still be reimbursing you less than what they pay to hospitals.

If you set out with a well-formulated argument and willingness to persevere, follow up, and persevere some more, you can successfully turn your bottom line around with better payer physical therapy reimbursement rates.

Get Support to Increase Your Physical Therapy Reimbursement Rates and Improve Profit Margins

Running a physical therapy practice is harder than ever. Inflation, declining reimbursements, and decreasing physician referrals require practice owners to step up their commitment and innovate if they want to succeed.

If you’re reading this, my guess is that you’re looking to increase profit margins and gain financial stability.

You don’t have to reinvent the wheel. Many practice owners have achieved success and want to share their knowledge and experience with other practice owners to benefit our industry as a whole.

That’s why Breakthrough has launched a new program called Profitability Under Pressure: A live 13-week masterclass exclusively for PT practice owners.

Through weekly calls, templates, group support, and one-on-one guidance, you will:

  • Conduct a financial analysis for your practice
  • Create a custom plan to increase your profits
  • Discover how to drop your lowest payer and renegotiate insurance contracts
  • Learn about the different cash-based services available and how to implement them
  • Start systematically attracting better-paying patients
  • Create consistency in your patient volume flow year-round

As part of this program, you’ll benefit from structure, accountability, community, and the accumulated shared knowledge of dozens of practice owners.

If you’re ready to increase your profit margins by $10K guaranteed, apply for Profitability Under Pressure today. You’ll learn even more keys to increasing profit margins, connect with like-minded owners, and find peace of mind with better safety buffers in your finances.

Profitability Under Pressure

Mary Daulong, Founder and CEO of BCMS, discusses the final rule of the 2023 CMS Physician Fee Schedule.

Medicare reimbursement cuts for physical therapists have been finalized for 2023.

On November 01, 2022, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the Medicare Physician Fee Schedule (PFS) and other Medicare Part B issues, effective on or after January 1, 2023. Here’s what we know. 

To help physical therapists and practice owners understand the final cuts to Medicare reimbursements in 2023, we’ve reassembled last year’s panel which discussed the 2022 Medicare Cuts.

Chad Madden, co-founder of Breakthrough, Mary Daulong and Alicia Mahoney—CEO and COO at Business & Clinical Management Services (BCMS)—linked up once more to discuss the 2023 changes to the CMS Physician Fee Schedule. They hosted a live Q&A with hundreds of interested practice owners and therapists. 

When you next have time, we highly recommend checking out the webinar recording

A summary of that conversation, including the key things you need to know about next year’s Medicare Cuts, is documented in this article.  

Q: What are the key changes proposed for the 2023 medicare payments?

A: In a nutshell…

  • The CY 2023 fee schedule conversion factor is $33.08, a 4.42% decrease (or $1.53) from the CY 2022—the lowest since the 1990s.
  • The Assistant Payment Differential (APD) is here to stay.
  • Assistant supervision is scheduled to expire at the end of 2022, but Medicare is proposing to extend the ability for therapists to conduct general supervision.
  • Therapists are still not on the permanent list of telehealth suppliers/providers.

Q: How can we minimize revenue reductions caused by the APD?

A: As much as many of us would love for this not to be the case, Assistant Payment Differential (APD) is looking more and more like it’s here to stay. When we look at our neighboring professions, we see how they have been dealing with it in a similar way for years. The good news is, there are actionable steps we can take to minimize revenue reductions caused by APD. These include:

  1. Avoiding co-managing a visit with an assistant. It lessens the administrative burden of counting time, which saves money
  2. Do not use assistants to help with evaluations and re-evaluations, as it will decrease the fee paid by Medicare
  3. Use assistants to perform the objective elements of Progress Reports, as this is not billable to Medicare

Q: Will Assistant Supervision rules be adapted or changed in 2023?

A: As many of you will know, during the pandemic therapists were allowed to conduct ‘general supervision’ of clients and patients which allowed for audio-visual supervision to take place as opposed to direct supervision. General supervision however is scheduled to expire at the end of 2022, although Medicare is proposing that it continues—despite not providing a clear target on the calendar. We will update our community as soon as we have a clearer consensus.  

Q: Are there any changes about who can and cannot provide Telehealth in 2023?

A: Therapists are still not on the permanent list of telehealth suppliers/providers. However, the House has passed the Advancing Telehealth Beyond COVID-19 Act. This bill that would extend the CMS waiver permits for telehealth by therapists until December 31st, 2024, regardless of the status of the Public Health Emergency (PHE). This is a great opportunity to write or call your state representatives and senators to see if they can take this further than 2024. 

Because of the PHE—as mentioned above—there is a temporary public health emergency waiver that allows telehealth to continue through the year that the PHE ends (currently set for 2023) +151 days. After these 151 days, practitioners will be required to use the following updated POS indicators for telehealth services:

  1. POS “02” – This code will be redefined if finalized as Telehealth Provided Other than in Patient’s Home
  2. POS “10” – This code would be redefined if finalized as Telehealth Provided in Patient’s Home

There are still geographical laws and regulations that must be abided by at a state level. For example, if you wish to provide telehealth to a patient in Florida whilst you’re in New York, your practice act must permit you to perform telehealth in both states.  

Q: What are the most common causes of Medicare audits and compliance costs?

A: Being routinely compliant across the board can save your business large amounts of money. This is especially important in today’s climate, as Medicare audits have skyrocketed and many private practices are getting stung simply by being underprepared and unorganized.

For Medicare, the most common audits were Post Payments, Supplemental Medical Review Contractors, and TPE audits. The most common HIPAA violations in 2021 were Illegal Access to PHI, Lack of Security Risk Analysis, and failure to have a Risk Management Process. OSHA violations that tripped up private practices included Failure to Provide Respiratory Protection, effective Hazard Communication, and PPE. 

Q: As practice owners, how do we deal with rising inflation and cuts to Medicare reimbursements?

A: A 4.4% decrease in Medicare reimbursements paired with 8-9% inflation (with a possibility of going higher) will be costly. Practices need to plan for a counteroffensive if they want to stay open and maintain profitability. The good news is, there are lots of tactics one can employ to improve profit margins, save on expenses and survive trying times such as these. You can: 

  • Optimizing staff schedules
  •  Minimize unnecessary overheads (like unused rental space)
  •  Attract patients — new and past patients

Q: What are 3 ways to increase our practice’s topline revenue?

A: In theory, it’s remarkably simple…

  1. Attract new patients
  2. Increase per patient revenue
  3. Reactivate past patients

It’s the execution that is the hard part. 

Breakthrough’s leading Patient Demand Platform makes it easy. Designed specifically for physical thearpy practices, the tool offers pre-built campaigns and automation that generate consistent, predictable revenue growth. 

Click here to schedule a demo.

Q: In our electronic medical records, why can’t both names show on the progress report document, or have a statement describing the exact involvement of the therapist and PTA?

A: Both names can appear on a Progress Report document, but the exact involvement of all parties from a regulatory perspective must be extremely clear so that when Medicare audits you, everything is above board. There must be proof the PTA has not done more than what they are allowed to. This is particularly important to do when you cannot simply eliminate your PTA from signing the report altogether. This doesn’t have to be a complex legal dissertation every time—it could be a previously written succinct statement that’s used universally throughout your clinic.

Q: Will we require an order from an MD in order to be paid from Medicare?

A: No. In short, to be paid by Medicare, your patient’s certified plan of care just needs to be laid out and accepted by their physician. It is always worth double-checking the legislation in your state of practice though. 

Q: How often are progress reports required, and does a Plan of Care certification need to be completed every 90 days? 

A: A progress report is required every 10th visit or less—there is no specific time frame attached to how often this is on a time/calendar basis. Plan of Care certification on the other hand, is on a time basis, and must be re-certified every 90 days

Q: How can we get reimbursed for treatments rendered if a patient self refers and begins the 10 sessions Medicare allows, but doesn’t get sign-off from their physician?

A: It is rare that a patient’s physician doesn’t sign the Plan of Care, as the physician has to comply with Medicare regulations. But in the rare case a patient’s physician doesn’t sign the Plan of Care, a Technical Denial occurs and the financial liability is then passed onto the patient. This is why it is really important to inform the patient that you are operating under a Plan of Care to avoid placing them in this financially vulnerable situation. If the physician still refuses to sign, speak with your patient and let them know that they will need to contact their doctor and request signature for the rest of the Plan of Care to continue under Medicare. 

Still unsure how you will navigate your business through the proposed 2023 medicare cuts? 

With proven tools, tactics, and strategies, the experts at Breakthrough can help you boost your profit margins, streamline your private practice and get you through 2023 and beyond. 

Schedule a call with our team today and we’ll plan your next step together.

2022 medicare reimbursements and guidelines

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 co-founder, 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 the new 2022 Medicare rules. We have been inundated by questions on Medicare PTA reimbursements, Medicare PT guidelines, and more upcoming cuts and implications. 

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. 

We held a webinar recently that covered a number of user questions and had a really great turnout. Take a look at the replay below:

Q: What are the key changes in the 2022 fee schedule and final ruling?

A: Here’s the big picture:

  • PTs will see a ~3.7% reduction in payment and OTs will see a ~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-staffede, 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 assignments of benefits. If you choose not to participate, you are choosing not to accept assignments, 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?

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