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Medicare Rule Changes for Physical Therapists Effective January 1, 2025

As we step into 2025, Medicare has introduced updates that bring more flexibility and reduced administrative burdens for physical therapists (PTs), occupational therapists (OTs), and their assistants. These changes aim to improve patient access to therapy services while addressing long-standing concerns in rural and underserved areas. Here's a breakdown of the key updates and what they mean for your practice.

General Supervision Policy for PTAs and OTAs in Private Practice

What's changing:

Starting January 1, 2025, physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) in private practice settings will be allowed to work under general supervision instead of direct supervision. This aligns the supervision requirements for private practice PTs and OTs with those working in institutional providers.

What it means for you:

Greater Flexibility: This policy gives PTs and OTs in private practice more leeway to structure care delivery, particularly in areas where staffing challenges exist.
Improved Access to Care: Beneficiaries in rural and underserved regions stand to benefit as therapy services can be delivered with less restrictive supervision.
Regulatory Alignment: The change aligns private practice supervision policies with those of institutional providers, simplifying compliance for PTs and OTs who operate across different settings.

Action items:

Review your practice's supervision protocols to align with the new rule.
Educate PTAs and OTAs on the changes to ensure they understand their responsibilities under general supervision.

Certification of Therapy Plans of Treatment

Medicare has finalized amendments to the certification requirements for therapy plans of treatment, significantly reducing administrative burdens.

What's changing:

Signature Requirement Exception: If a written order or referral from the patient's physician or non-physician practitioner (NPP) is on file, the therapist-established treatment plan does not need a separate physician/NPP signature for initial certification. The therapist must document evidence that the treatment plan was transmitted to the physician/NPP within 30 days of the initial evaluation.
No Timeline Restriction on Modifications: CMS did not adopt a specific timeframe within which a physician/NPP could modify the treatment plan. Payment will still be made for services rendered prior to any modification, provided all payment requirements are met.

What it means for you:

Reduced Administrative Tasks: Therapists can focus more on patient care instead of chasing signatures for initial treatment plans.
Payment Safeguards: Therapists are assured of payment for services provided before a physician/NPP-modified treatment plan, as long as the plan was transmitted in compliance with Medicare's requirements.
Clear Documentation Standards: While a timeline restriction was not established, therapists should ensure robust documentation to avoid disputes over treatment plans.

Action items:

Update internal protocols to incorporate the new signature exception.
Ensure treatment plans are transmitted to the physician/NPP within 30 days and maintain thorough documentation as evidence.
Communicate with physicians and NPPs about the change to streamline collaboration.

Stay Informed and Stay Compliant Moving Forward

These CMS updates are designed to improve access and ease administrative strain for providers. Still, caution is necessary; stay informed, update your practices, and remain vigilant in maintaining compliance.

For additional guidance, visit CMS's official website or consult with your Medicare Administrative Contractor (MAC) to ensure compliance with these new rules.

Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CMPM, CPMN, is the Director of Coding and a partner at DoctorsManagement, as well as the founder and president of NAMAS. Shannon brings more than 16 years of multi-specialty auditing and coding experiences to DoctorsManagement clients, helping practices optimize business processes and maximize reimbursements.

Medical Auditing Training, Medical Coding Audit Services

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Spotlight on February 2025 FWA

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Spotlight on January 2025 FWA

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Why HR Compliance Is Crucial for Your Medical Practice

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The Night Before Auditing (A Medical Auditor's Tale):'Twas the night before auditing, and all through the floor, The auditors prepped, ready to explore. The charts were all stacked, each file in its place, While audit reports awaited their grace.

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Overcoming Prior Authorization Challenges With Technology:Patient Harm: Nearly one in four physicians (24%) reported that prior authorization has led to serious adverse events, including hospitalization, permanent impairment, or death. Furthermore, 93% of physicians observed a negative impact on clinical outcomes, and 94% noted delays in accessing necessary care, often causing patients to abandon their treatment due to struggles with health insurers.

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Types of Healthcare Audits:Healthcare audits are essential for analyzing operational compliance and adherence to quality standards. Also called clinical or medical audits, these processes generally assess where providers and staff are doing well and where they can improve. Audits in healthcare can support an improved patient experience, staff accountability, and healthier revenue cycle management (RCM).

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CMS Report Highlights Complaints and Enforcement Actions Under the No Surprises Act:This week, the Centers for Medicare and Medicaid Services (CMS) released a report detailing complaints and enforcement actions related to the Public Health Service Act, which encompasses the No Surprises Act.

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Enterprise-Based Denial Management: A Comprehensive Approach:With denied claims rising – up 10.15% in 2020, 11.2% in 2022, and then 11.99% in 2023 (according to Fierce Healthcare) – it is clear that healthcare organizations face an escalating challenge that demands a comprehensive, thorough strategy.

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Auditing Surgical Services:While E&M auditing continues to be the industry favorite for professional medical auditors in this field, there are several reasons and opportunities to audit surgical services.

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California Made Capitation Payments for Enrollees Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Another State:California pays managed care organizations to make services available to eligible Medicaid enrollees in return for a monthly fixed payment (capitation payment) for each enrollee.

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Auditing the Global Package:When auditing provider services, what is the best method to approach the concept of a global package? Some rental companies provide a renter with all-inclusive pricing for an apartment. The payment arrangement covers heating, electricity, water, and garbage for the one-bedroom apartment.

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Modernizing Auditing and Compliance in Healthcare:The Importance of Auditing - Regular auditing of medical charts and coding documentation is indispensable for identifying errors, ensuring regulatory compliance, and reducing the risk of fraud. Audits not only uncover coding inaccuracies but also offer valuable insights into areas for improvement within the organization's processes and procedures.

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Monthly Spotlight on Fraud, Waste, and Abuse:The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services.

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HHS Modifies Rule for Confidentiality of Substance Use Disorder Records - HHS Issues Final Rule:On February 8, 2024, the Department of Health and Human Services (HHS) announced that it had approved the modification of rules regarding the confidentiality of patient Substance Use Disorder (SUD) records. After careful consideration of public comments, the HHS determined that approval of the Final Rule would improve coordination of care, and, ultimately, the quality of patient care.

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AI Auditing: Walking Backward Toward Home:Way back in 1976, as an elementary school kid in the suburbs of Philadelphia, I came across a book in the library called 2010: Living in the Future. In my then-current world of AMC Pacers and seersucker suits, the book promised great things.

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The Audit Process :I hold a LinkedIn Live broadcast called Health Care Happenings that also airs on Facebook and YouTube every other Thursday, in which I discuss different healthcare topics. I recently did a three-part series on auditing: Preparing for the Audit, Performing the Audit, and Providing the Audit Results. This article will expand on that series to discuss the audit process.

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Maximize Duplex Doppler Ultrasound Documentation and Reimbursement:Complete documentation of any radiology procedure is the key to appropriate reimbursement. This is especially true for venous duplex Doppler ultrasound exams, where including fewer than the required number of elements for a complete procedure will result in reimbursement for a limited study.

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Monthly Spotlight on Fraud, Waste, and Abuse - August 2023:The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services.

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If Conduct Appears to Buck the Legal Norm, Chances Are That It Does:It's akin to wearing Doc Martens to a professional cocktail party reception or Uggs to court. In other words, the wardrobe choice jumps out as not being appropriate for the situation. Likewise, certain conduct that violates the Anti-Kickback Statute (AKS) and the False Claims Act (FCA) unequivocally jumps out as being unlawful under the facts and circumstances, yet persons engage in the inappropriate behavior.

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As CMS Focuses on Quality, There Are Monumental Changes to Reimbursement for Quality on the Horizon!:The Centers for Medicare and Medicaid Services (CMS) utilizes risk adjustment factors to estimate the cost of Medicare Advantage (MA) beneficiaries and those associated costs of providing care. Risk adjustment factor scores govern the amount paid by the health plan during the year for the beneficiary's care.

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Choosing the Right Tool: Targeted vs. Random E/M Audits:The realm of E/M (evaluation and management) auditing is vast, and 2023 will bring more work here than before thanks to CPT's extensive revisions to its E/M guidelines for inpatient, facility, and home visit services - now in effect. Both compliance professionals and providers must always keep in mind that E/M services (which account for a third of annual Medicare Part spending) will go from being a perennial easy target to an urgent area of attention in 2023.

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Who Can It Be Knocking at Your Door? Are You Prepared? :The truth is, you can never be fully prepared when a Special Investigative Unit (SIU) from Medicare or Medicaid shows up unannounced.

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Self-Audits:Self-audits are critical. They demonstrate compliance, or at least a "good-faith effort" to be compliant; they minimize refunds of overpayments to "actuals" and also mitigate the potential for a multiple being added.

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Provider Education: The Most Important Step of the Audit Process:You've taken the time to complete a painstaking audit of a provider, combing through their documentation on an EHR or maybe even navigating through a handful of handwritten notes.

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Modifier 25 Pre-Bill Review: Were You Ready?:After all the hype surrounding the upcoming Cigna policy regarding modifier 25 and pre-bill reviews, it seems as if Cigna is not planning on implementing the policy as planned on August 14, 2022.

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Navigating the UPIC Investigation from a Compliance Consultant's Perspective:Over the past year and a half, I have seen a significant increase in the volume of Unified Program Integrity Contractor (UPIC) investigations taking place in private physician practices.

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Culture in Compliance:For years, we have talked about the culture in healthcare, especially for compliance purposes, but for many practices, that culture takes a backseat despite continued guidance.

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2022 Annual Audit Elements: What Should Be Reviewed:Four months into 2022 and the question is: How far along is your audit of high, medium, and low-risk services? If you are like most practices or health systems, something always gets in the way and causes audits to take a back seat.

Auditing

Should Your 2022 Audit Plan Include Paid Claims?:In 2022, when we sit down to configure an audit plan, we often consider whether we will perform an audit retrospectively or prospectively, and whether the sample will include evaluation and management (E&M) services, procedures, or some combination of them both.

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Don't Sleep On Small Claims Denials:Are you ever tempted to just sweep those small claims denials under the rug? Do you sometimes wonder if it is worth the time and effort to figure out why a code, which will end up yielding $30, is being denied? Does it feel like it takes years to understand a denial and find a solution - leaving you to question if you really know what you are doing? I've had many of those moments.

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Auditing Infusions, Hydrations, and Injections:If your facility and/or practice is providing infusion, hydration, and injection services, they should be included in your annual compliance auditing plans to ensure proper coding guidelines are being followed and documentation education is not necessary to assist with any loss of revenue gaps.

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Ciox: Not a Bleach, But Not to Be Ignored:In my role as a compliance consultant specializing in carrier audit response, a lot of items are brought to my attention on a daily basis, with the bearer of said items asking questions

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Acute Uncomplicated vs Complicated Illness or Injury:When selecting Number and Complexity of Problems Addressed, the complication of treatment required should not be considered. The Risk of Complications of Patient Management is where the treatment options are considered in code selection.

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Getting Serious About Compliance:By now, most health systems, practices, and providers should know that the Office of Inspector General (OIG) has been stressing the importance of creating and abiding by a compliance plan since the passage of the patient Protection and Affordable Care Act in 2010.

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HHS/OIG Exclusion List Violations:An important subject that should not be far from your mind is the OIG exclusions list. The HHS/OIG is not backing down on Employment of Excluded Individuals.

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OIG Plans for Onslaught of Risk Adjustment Audits Claiming 9.5% Error Rate in Code Assignment:According to an Office of The Inspector General Report, the Centers for Medicare & Medicaid Services (CMS) estimate that 9.5% of all payments to Medicare Advantage organizations are improper due to unsupported diagnoses submitted by the organizations themselves.

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TPE Audit Program Resumption:On Thursday August 12, CMS put providers on notice that the TPE audit program was kicking off again after more than a year hiatus due to the public health emergency (PHE)! As you can imagine, there is some chatter about when and what to expect once the letters start going out.

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The Year of the Audit: Stand Your Ground with Payers:Over the years I have worked with so many wonderful and talented auditors and professionals at Blue Cross Blue Shield payers, UHC, Aetna, CIGNA, Humana, Medicare carriers, etc.

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2021 E and M Changes - Diagnoses in the MDM :

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It is My Organization: I Can Do What I Want:The age-old question of Can we offer cash-pay discounts, professional courtesy and/or the waiver of co-payments or deductibles continues to be as relevant today as it was 2-decades ago.

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Avoiding a Compliance Nightmare in 2020:I've never been a huge fan of horror films and not because of the blood and guts but simply because of the bad choices the victims always seem to make;

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OIG Compliance 101 - Ensuring the Next Generation is Prepared:

Each day our industry gains new members who are eager to learn and make a difference in the organizations in which they work.

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EM Changes for 2021 Help is Out There:the hardest part of our job going forward will be in shaping documentation of assessments

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Why is HIPAA So Important:Some may think that what they do to protect patient information may be a bit extreme.

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Medical Necessity and The False Claims Act:With so many things to consider regarding why compliance needs to be established

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Auditing for Reimbursement:

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Auditing

Joint Commission and the Value of Accreditation:Around the world accreditation is used to assure a high baseline level of healthcare quality. In the United States, accreditation is a multi-million-dollar industry without any sign of slowing down because it's compulsory for federal payments and a marketing necessity in an increasingly competitive landscape.

Auditing

New DOJ Guidance on Evaluating Corporate Compliance Programs:The DOJ's guidance document sets forth topics and questions to address three fundamental questions that prosecutors ask when evaluating compliance programs to guide its investigation:

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You CAN Charge Medicare More Than You Charge Some Patients:there is no governmental requirement that a clinic have a uniform charge for all payers

Auditing

But All My Friends are Doing it:Just because friends or colleagues are doing something doesn't mean it's the right

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Lost in a Pile of Numbers Are Your Doctors Who They Say They Are:one of my primary projects is predicting the likelihood that a particular provider may be audited

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OIG Compliance 101 - Ensuring the Next Generation is Prepared:Each day our industry gains new members who are eager to learn and make a difference in the organizations in which they work.

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Anthem is Changing their Timely Filing Requirements for All Plans Including Medicare Advantage:Anthem has been very busy sending out notices

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What about Midnight Billing for Time Across Calendar Days:the calendar day is defined as lasting from midnight to midnight

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Extrapolation Policies Apply to RADV Audits:Risk Adjustment is a program that was implemented to identify and support Medicare

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Small Breaches Can Be Subject to Large Penalties :We may have heard about the large fines issued by the Office for Civil Rights

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HIPAA Changed Again Are You Compliant:The most common violations that providers encounter will occur under Tier One or Tier Two.

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Auditing Hospitalist Services:The inpatient side of coding and auditing can be enormously complex

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I Know What We’re Doing is Wrong I Need My Paycheck:Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment

Auditing

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Prolonged Services :I find in my own audit reviews that the prolonged service code set is often mistreated

Auditing

Voluntary Repayments:cShould you volunteer to repay money from Medicare or other federal healthcare programs

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Auditing

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Medical Necessity vs Documentation for Inpatient Services :Many of the notes we are provided for review include so much information

Auditing

Medical Student Documentation CMS Relaxing of the Rules:Medicare Claims Processing Manual to allow the teaching physician

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What is Virtual Communication G0071:This visit descriptor is Virtual Communication and is not indicated as a telehealth service

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Billing 99211 Its not a freebie:It seems like a simple code to bill

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Using a Billing Company versus Hiring a Biller When Starting a Medical Practice:The option I do not recommend is the option that requires hiring a biller.

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We've Always Done It This Way and Other Challenges in Education:This is one sentiment that we all have had at one time

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Prolonged Services Its Not Just About Time:One way of looking at this is to take note of the threshold times

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Auditing

The Potential Impacts of a Flat Rate EM Reimbursement on our Industry:Proposed Reimbursement Model Change

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Auditing

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Auditing

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Auditing

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Auditing

Provider-Based Facilities and Split Billing Is Your Facility Being Reimbursed for All Work Performed?:Are you stumped by billing guidelines for provider based facilities

Auditing

Auditing Therapy Evaluation Codes Not So Quick:New evaluation codes for physical therapy

Auditing

TKAs to Outpatient What We Have Learned with Q1:The release of the 2018 Final Rule for the Outpatient Prospective Payment System

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