Physical and occupational therapists are included in the types of providers required to participate in CMS’s Quality Payment Program and report Merit-Based Incentive Payment System (“MIPS”) measures.
The following FAQs address how inclusion of PTs and OTs for the 2020 reporting year impacts physician groups and their therapists.
Who is required to report and, if so, how to report?
There are two ways that physicians, PTs, OTs and other providers in a group practice can report for MIPS-as a group or individually. If a physician groups reports as a group, PTs and OTs are 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 2020, you will need to determine whether each individual PT and 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, inclusion of PTs and OTs as eligible providers should not significantly increase your reporting burden and should help to increase your reporting bonus. Physician groups that report as a “group” typically 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 PT/OT referrals from outside physicians.
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 2020, that will be the only time during the 2020 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 70% of all patients.
How can PTs and OTs help a physician group meet its reporting requirements?
If a physician group is reporting quality measures that apply to the physician specialty, physician reporting will generally cover PTs and OTs because patients are shared. PTs and OTs can help with reporting depending on the quality measure. Quality measures for 2020 that are shared by orthopedic surgeons, PTs and OTs are:
- 128 Preventive Care and Screening: Body Mass Index
- 130 Documentation of Current Medications in the Medical Record
- 154 Falls: Risk Assessment
- 155 Falls: Plan of Care
- 182 Functional Outcome Assessment
- 217 Functional Status Change for Knee Impairments
- 218 Functional Status Change for Hip Impairments
- 219 Functional Status Change for Lower Leg, Foot or Ankle Impairments
- 220 Functional Status Change for Patients with Low Back Impairments
- 221 Functional Status Change for Patients with Shoulder Impairments
- 222 Functional Status Change for Patients with Elbow, Wrist or Hand Impairments
- 226 Preventive Care and Screening: Tobacco Use
- 318 Falls: Screening for Future Fall Risk
- 478 Functional Status Change for Patients with Neck Impairments
In addition, PTs and OTs can help relieve some of the physician reporting burden by reporting on quality measures that only apply to PTs and/or OTs. For example, quality measure 126 for Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy can be used by PTs, but not orthopedic surgeons. This allows a group’s PTs to help the group meet one (or even more) quality measure reporting requirements by providing screening and appropriate follow-up plans only for patients seen by PTs. Quality measures for 2020 that apply to PTs and/or OTs, but not orthopedic surgeons are:
- 126 Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy
- 127 Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention
- 134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan
- 181 Elder Maltreatment Screen and Follow-Up Plan
- 281 Dementia: Cognitive Assessment
- 282 Dementia: Functional Status Assessment
- 288 Dementia: Education and Support of Caregivers for Patients with Dementia
Note that while PT/OT reporting may satisfy some quality measure reporting requirements as explained above, improvement activities must be performed by at least 50% of the clinicians in a group so reporting by PTs and OTs alone is unlikely to meet this requirement.
What if our PTs and OTs accept outside referrals?
If you are reporting as a group, you need to report on 70% of the group’s patients (regardless of payer). Even if, for example, 10% of your PT patients are from outside referrals, this should not prevent the group from reporting on 70% of all patients. For example, if your physicians treat a total of 1,000 patients during 2020 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 70% reporting requirement.
Also, if your group will be reporting on quality measures that are not reportable by PTs or OTs, outside PT/OT referrals should be irrelevant. (The 2020 PT/OT quality measures are listed above.)
We can help you determine whether outside PT/OT referrals will affect your MIPS reporting.
If our physicians report individually, how does this affect our PTs and OTs?
If your physicians will report individually for 2020 (which is rare), you will need to determine whether each therapist is required to report (see below). If an individual therapist is required to report, he or she only needs to report quality and improvement measures for 2020. For therapists, quality measures count for 85% and improvement activities count of 15% of MIPS scores. 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 for both October 1, 2018-September 30, 2019 and October 1, 2019-September 30, 2020:
- $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.
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 2020 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, 2020 under any other enrollment as an individual or through a group.
PLEASE NOTE THAT YOU ONLY NEED TO DETERMINE WHETHER A PT OR OT IS REQUIRED TO REPORT IF YOUR GROUP REPORTS ON AN INDIVIDUAL BASIS.
If our physicians report individually and a therapist is not required to report, can and should the therapist opt into reporting?
If your group reports individually and a therapist is not required to report because he or she is not above all three of the eligibility thresholds explained above but exceeds one or two of the thresholds during either 12-month testing period, he or she can opt into reporting and potentially receive a bonus in 2022. Although the bonus potential is 9% 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 2020 maximum bonus will be about 2% and it is quite likely that future years will follow this pattern. At the same time, the maximum penalty is 9%.
So, therapists who are contemplating opting in must weigh the possibility of receiving a bonus of about 2% against the burden of reporting on six quality measures for at least 70% of all patients, reporting on improvement activities (see below) and the possibility of a penalty of up to 9%. Therapists who do not opt in are not required to report any measures and are not subject to the penalty.
Our recommendation is to not opt in because the reporting burdens and potential penalty do not outweigh the potential benefit.
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 quality measures on at least 70% 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). https://qpp.cms.gov/mips/improvement-activities
What 2019 PT/OT quality measures were deleted for 2020?
- 131 Pain Assessment and Follow-Up
- 223 Functional Status Change for Patients with General Orthopedic Impairments
