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Insurance Payor Updates Distract Family 2023 Summer Vacations

As the 2023 summer season comes to an unofficial end this Labor Day weekend, everyone should take a moment to take a few deep breaths. One of the largest commercial insurance payors in the country decided to take several strategies from the CMS playbook and announce 2023 summer updates impacting outpatient therapy practices. On July 1st of this year, UnitedHealthCare (UHC) revised its medical policy that outlines coverage requirements such as documentation standards for Physical, Occupational and Speech therapist on outpatient practice.


A highlight in this manual was the requirement for listing the “start and stop time in treatment” for each treatment session as well as clearly listing the “individual’s response to treatment, skilled ongoing reassessment of the individual’s progress toward the goals, and the plan of care must be signed and dated by the referring provider.” This medical policy is also a great resource for locating procedure and/or diagnosis codes that are considered covered or non-covered as per UHC.


However, only a few weeks later on August 1, 2023 did UHC again update its medical policy (via another revision). UHC retracted the plan of care language and removed this administrative burden for therapists (see page 9 in Habilitation and Rehabilitation Therapy (Occupational, Physical, and Speech Therapy) – Commercial and Individual Exchange Medical Policy (uhcprovider.com)).


Not to be outdone, CMS released their calendar year 2024 Medicare Physician Fee schedule in mid-July. The negative financial impact of this proposal is estimated to be between a 3-4% decrease in payments depending on the selection of CPT codes and services provided. The “Threshold” amount is $2,330 for PT+SLP services and the same amount for OT services. Three new caregiver education CPT codes are scheduled to be released for our billing options, so if you have been wondering how to capture the caregiver education time during your daily treatments, this will be a welcome adjustment to diversify your coding.


On a positive note, the outpatient direct supervision carve-out that has been oddly applied just for outpatient facilities may see a reprieve in the near future if we are allowed to apply “immediate availability” from a supervision perspective (which has already been proven to be effective during COVID). Therapists would then be allowed to avoid the direct supervision standard when a supervising therapist is immediately available through real-time audio/visual interactive communications. This would also allow for greater consistency surrounding regulatory standards in states that allow PTAs to practice with limited oversight (e.g., required treatment by a PT every 6th visit).


As expected, CMS will continue to cover telehealth services in 2024 with the place of service code 10 (paid at the non-facility rate) and place of service code 2 (paid at the facility rate), so take note of which place of service code you are appropriately selecting. The CMS contractor Noridian announced on July 31st, a correction to their guidance that previously listed re-evaluations (97164) as a non-covered service when performed via telehealth by licensed therapists. As scheduled, MIPS reweighting occurred; however, MIPS value pathways (MVPs) will be taking over shortly (a musculoskeletal category is now active), so don’t become too comfortable with this reporting mechanism since a more refined ICD-10/diagnosis type of comparison is likely to be implemented. As a reminder on coding, always select the most therapy-specific ICD-10 diagnosis code that represents what you are treating, measuring, and targeting as a functional goal in therapy.

If this wasn’t enough to distract your summer family vacation, now we all must wait for the CMS 2024 “final rule” to be released towards the end of October/early November. The APTA has excellent resources available and for the second year, the “comment tool” should be your first choice to address these 2024 proposals that will absolutely impact your practice by drafting a personalized comment to CMS. A few minutes of your time to promote your profession when it matters most is absolutely a smart investment and strongly recommended.


If you’re looking for a company that offers affordable and robust compliance solutions for your outpatient therapy practice, contact Risk & Compliance Analytics and be amazed how simple we’ve made it. We provide exactly what you have been looking for!



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