2019 MIPS REPORTING BY ORTHOPAEDIC GROUP BASED PHYSICAL AND OCCUPATIONAL THERAPISTS
December 12, 2018
Starting in 2019, physical and occupational therapists are included in the types of providers who participate in CMS’s Quality Payment Program (“QPP”) and start reporting Merit-Based Incentive Payment System (“MIPS”) measures.
The following FAQs address how inclusion of PTs and OTs for the 2019 reporting year impacts orthopaedic groups and their therapists.
Who is required to report and, if so, how to report?
There are two ways to report for MIPS-as a group and individually. If you report as a group, the PTs and OTs will be automatically included as eligible providers in basically the same manner as physicians and PAs. If your physicians and other eligible providers will report individually for 2019, you will need to determine whether each individual PT/OT is required to report, has the option to report (and possibly receive a bonus) or is not eligible to report (see below).
If we report as a group, how does inclusion of PTs and OTs affect us?
If you report as a group, addition of PTs and OTs as eligible providers should not significantly increase your reporting burden and should help to increase your reporting bonus. Orthopaedic groups that report as a “group” necessarily focus on meeting reporting requirements for physicians. If you meet the group reporting requirements for your physicians, you will almost undoubtedly meet the requirements for PTs and OTs because your PTs and OTs are treating the same individual patients as your physicians with a few exceptions for outside referrals.
For example, if you are reporting as a group on BMI (#128), you only need to include an individual patient (e.g., Mr. Jones) once per year. If Mr. Jones’ BMI is documented during his visit to one of your physicians during 2019, that will be the only time during the 2019 reporting year that any provider in your group will need to report BMI for Mr. Jones. If Mr. Jones is referred for PT, his BMI has already been documented and his treatment by a PT does not increase your number of patients in a way that impacts your required reporting on 60% of all patients.
What if our PTs and OTs accept outside referrals?
If you are reporting as a group, you need to report on 60% of your patients (regardless of payer). Even if e.g., 10% of your PT patients are from outside referrals, this should not prevent the group from reporting on 60% of all patients. For example, if your physicians treat a total of 1,000 patients during 2019 and report BMI for 800 of these patients, the fact that PT may have 100 outside referrals whose BMI is not documented does not prevent the group from meeting the 60% reporting requirement.
Alternatively, if your group will be reporting on six MIPS measures that are not reportable by PT/OT, outside PT/OT referrals should be irrelevant. (The PT/OT MIPS measures are listed at the end of these FAQs.)
If our physicians report individually, how does this affect our PTs and OTs?
If your physicians report individually, you will first need to determine whether each therapist is required to report. If an individual therapist is required to report, he or she only needs to report MIPS and quality improvement measures for 2019. QPP cost and interoperability measures do not apply to therapists.
If our physicians report individually, how do we determine whether a therapist is required to report?
A therapist is required to report if he or she is above all three of the following thresholds from both October 1, 2017-September 30, 2018 and October 1, 2018-September 30, 2019:
• $90K in Medicare Part B allowable charges
• 200 individual Medicare patients
• 200 professional services (each line item is a professional service)
For practical purposes, the 200 individual Medicare patient threshold will govern whether a therapist is required to report because if a therapist has treated 200 or more individual Medicare patients during both of the 12-month measuring periods, that therapist has almost certainly exceeded $90K in allowable charges and 200 professional services.
To determine whether a therapist (or any provider) is above the thresholds, you should use the provider participation look-up tool at https://qpp.cms.gov/participation-lookup. However, you will need to wait until January to check on 2019 participation status of PTs and OTs.
CMS estimates that a very low percentage of therapists will be required to report because most therapists treat fewer than 200 individual Medicare patients during a 12-month period. If your traditional Medicare patient population is under 30% of your total patient population, it is very unlikely that your therapists will be required to report. Keep in mind that a therapist is not required to report if he or she is under any one of the three thresholds during either of the 12-month testing periods mentioned above.
Also, a therapist who is first enrolled with Medicare in 2019 is not required to report. To be considered a new Medicare-enrolled eligible clinician, clinicians cannot have submitted claims to Medicare prior to January 1, 2019 under any other enrollment as an individual or through a group.
If a therapist is not required to report, can and should the therapist opt into reporting?
If a therapist is not required to report (as explained above) but exceeds any one of the thresholds during either 12-month testing period, he or she can opt into reporting and potentially receive a bonus in 2021. Although the bonus potential is 7% of Medicare payments, the actual payment is based on participation by all other eligible Medicare providers because MIPS is “revenue neutral” which means that bonuses are only paid from penalty collections. The year 1 maximum bonus was 1.9% and it is quite possible that future years will follow this pattern. At the same time, the maximum penalty is 7%.
So, therapists who are contemplating opting in must weight the possibility of receiving a bonus of about 2-3% against the burden of reporting on six MIPS measures for at least 60% of all patients, reporting on improvement activities (see below) and the possibility of a penalty of up to 7%. Therapists who do not opt in are not required to report any measures and are not subject to the penalty.
A therapist who decides to opt in must do so via the QPP portal (https://qpp.cms.gov/login). An election to opt in for a reporting year cannot be reversed.
If a therapist is required to individually report or opts in, what does he or she need to do?
If a therapist is required to individually report or opts in, he or she will be required to:
(a) report on at least six PT/OT MIPS measures on at least 60% of all patients across all payers (not just Medicare) www.qpp.cms.gov/mips/quality-measures and
(b) report “improvement activities” (two high-weighted activities or one high-weighted and two medium weighted activities or four medium-weighted activities).
CMS has not yet published the final 2019 MIPS measures or improvement activities. These are expected in January 2019.
What are the PT/OT MIPS measures for 2019?
The MIPS measure number and description for PT/OT measures are listed below. Keep in mind that as of the date of these FAQs, CMS has not finalized the 2019 measures so more details will be forthcoming.
128 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up
130 Documentation and Verification of Current Medications in the Medical Record
131 Pain Assessment and Follow-Up
182 Functional Outcome Assessment
217 Functional status change for patients with knee impairment (FOTO)
218 Functional status change for patients with hip impairments (FOTO)
219 Functional status change for patients with foot or ankle impairment (FOTO)
220 Functional status change for patients with lumbar impairment (FOTO)
221 Functional status change for patients with shoulder impairment (FOTO)
222 Functional status change for patients with elbow, wrist, or hand impairment (FOTO)
223 Functional status change for patients with general orthopedic impairments (FOTO)
155 Falls Risk assessment and plan of care
126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy:
127 Diabetic Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention Evaluation