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Clarice Grote, MS, OTR/L

2022 Medicare Regulation Changes

Happy new year and happy holiday season to all who are celebrating! Here are the 2022 Medicare regulation changes coming your way on January 1, 2022

The OTA Modifier Payment Reduction

The OTA Modifier reduction will take effect on January 1, 2022. This payment reduction is applied to all Medicare Part B settings except for critical access hospitals. So, if you bill Medicare Part B in hospital outpatient, private practice, skilled nursing facilities, home health, hospital observation stays, or any other setting, this applies to you! The Centers for Medicare & Medicaid Services (CMS) calculates the 15% reduction as taking 15% off the 80% Medicare pays for therapy outpatient services. The calculation looks like this 20% + (80% – (80% * 15%)) = total payment.

So, the overall payment loss is 12%. What we don’t know is if supplemental plans will implement the 15% reduction as well for copays. However, we have yet to see any indication that supplemental plans will do that. To learn more about the OTA modifier, check out this article. If the SMART Act passes the House and Senate, the above may be obsolete. You can also learn more by listening to my first podcast episode that discusses the OTA Modifier.

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Home Health Value-Based Purchasing

Home Health Value-Based Purchasing (HHVBP) was trialed in 9 states (AZ, FL, IA, MD, MA, NE, NC, TN, WA) and resulted in over $100 million in average yearly savings as well as an improvement in overall quality outcomes for home health agencies. CMS decided to expand HHVBP nationwide starting January 1, 2023. CMS also bumped up overall reimbursement for home health by 3.2% which is about $570 million.

You may have noticed that the HHVBP isn’t starting until 2023. Now, why did I include it on this list? Because it is never too early to start preparing. If you haven’t been paying close attention to quality outcomes, now is the time to start. It’s time to start training staff on the upcoming changes as well as the OASIS-E. Don’t start next year off on the wrong foot. Reporting on the new quality measures is not required for 2022 but will be in 2023.

In this rule, we expand the Home Health Value-Based Purchasing (HHVBP) Model to all Medicare-certified HHAs in the 50 States, Territories, and the District of Columbia beginning January 1, 2022 with CY 2022 as a pre-implementation year. We are finalizing that CY 2023 will be the first performance year and CY 2025 the first payment year, based on HHA performance in CY 2023. We are also finalizing our proposal to end the original HHVBP Model one year early for the HHAs in the nine original Model States, such that CY 2020 performance data would not be used to calculate a payment adjustment for CY 2022.

CMS Final Rule – 42 CFR Parts 409, 424, 483, 484, 488, 489, and 498
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With value-based purchasing, quality outcomes are can make or break an agency. Under VBP, CMS reimburses care based on quality measures. So agencies that demonstrate high-quality outcomes receive incentive payments and agencies that provide low-quality outcomes, may face financial penalties. Additionally, poor quality outcomes often mean fewer referrals to your program. So, practitioners and program leaders alike need to come together and develop a strategy to best manage these coming changes. As stated in the final rule, the financial adjustments will not take place until 2025 so plenty of time to prepare.

Recommendations to achieve positive outcomes under HHVBP

  • Provide comprehensive OASIS Training to all staff who are eligible to score (RN, OT, PT, SLP)
    • The OASIS is where many of the quality measure reports are drawn from.
  • Utilize the most appropriate clinician to score OASIS items based on patient needs and characteristics
    • The OASIS is intended to be an interdisciplinary assessment. So, make sure the most appropriate clinician is available to score each section of the OASIS or to initiate the OASIS. OTs, PTs, and SLPs are eligible to initiate the OASIS on any case under the public health emergency, and once the PHE ends, OTs, PTs, and SLPs can initiate the OASIS in therapy-only cases.
  • Perform a review of your agencie’s outcome measures and see how you compaire to other agencies.
  • Identify areas for improvement and strengths and identify how your team can improve those outcome measures.

If you really want to be ahead of the game, start preparing for the OASIS-E which will premiere on January 1, 2023.

Occupational Therapists can permanently initiate the OASIS in therapy-only cases

CMS expanded the conditions of participation to allow occupational therapists to initiate the start of care OASIS and comprehensive assessment for therapy-only cases. This final rule did not change if OT is a qualifying discipline. It is worth noting here that the PHE is currently in effect until January 16, 2022, and it is expected to be expanded further.

While the PHE is in effect the flexibility allowing OT, PT, and SLP to initiate the OASIS in all cases is still in effect. So, once the PHE ends, OT, PT, and SLP will be eligible to initiate the OASIS in therapy-only cases, or home health cases without nursing the original order. To learn more about this flexibility, read this article.

Coding Updates from the National Corrective Coding Initiative (NCCI)

The National Corrective Coding Initiative (NCCI) announced an edit update to codes 97530 + 97535, 97530 + 97533. Effective January 1, 2022, CMS removed PTP edits for the above codes thanks to AOTA Advocacy. PTP edits are Procedure-to-Procedure codes. CMS defines PTP codes pairs as codes that should not be reported together without an appropriate modifier.

So, long story short, you no longer need to use a modifier when billing code 97530 (therapeutic activity) and 97535 (self-care) on the same day or when you bill 97530 (therapeutic activity) and 97533 (Physical Medicine and Rehabilitation Therapeutic Procedures) on the same day.

Should you decide to look at the chart, If you look at the chart Column 1 is the payable code and Column 2 contains the code that is not payable with Column 1 unless a Modifier is submitted and allowed. Depending on what chart you are looking at, Column 3 or 6 indicates if a modifier is allowed or not. A “1” indicates that a modifier can be used for these paired codes. When you download the charts from CMS, you will see one of the excel tabs is labeled “NCCI_Dels_Eff_01-01-2022” and those are the deleted code pairs effective Jan 1, 2022. Let me know if you have any questions and I’ll do my best to help. You can also contact if you are a member!

Medicare Sequester and Pay-Go

You may have seen a call to action earlier in the month of December to ask Congress to take action on the Medicare sequester and pay-go that posed a potential 6% overall cut to Medicare spending. Well, Congress heard our advocacy efforts and delayed the pay-go until 2023 (4% potential reduction) and has staggered the Medicare sequester to be implemented throughout 2022.

The sequester will decrease Medicare Fee-For-Service spending by 2% by the end of the year. There will be no change until April 1, 2022. April 1 – June 30, 2022, will have a 1% cut and July 1, 2022, and onward will have a 2% cut. So, we can expect another call to action later this year.

To learn more about the Medicare sequester and pay-go you can listen to my podcast episode. Keep in mind, it was recorded before the passage of the legislation mentioned above.

SNF Payment Rates

CMS announced an increase of approximately $410 million for Medicare part A spending on SNF for the fiscal year 2022.

This estimate reflects at $411 million increase from the update to the payment rates of 1.2%, which is based on a 2.7% SNF market basket update, less a 0.8 percentage point forecast error adjustment and a 0.7 percentage point productivity adjustment, and a $1.2 million decrease due to the proposed reduction to the SNF PPS rates to account for the recent blood-clotting factors exclusion (see below). These impact figures do not incorporate the SNF VBP reductions that are estimated to be $184.25 million in FY 2022.

Centers for Medicare & Medicaid Services

CMS also updated the ICD-10 Code mappings for sickle-cell disease, esophageal conditions, multisystem inflammatory syndrome, neonatal cerebral infarction, vaping-related disorder, and anoxic brain damage. The Consolidated Appropriate Act, 2021 also included provisions to expand the SNF VBP program beginning in FY 2024. This VBP hopes to better align quality measures between SNF and long-term care facilities as approximately 94% of SNFs are dually certified as a SNF and nursing facility.

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Clarice standing in a light room smiling wearing black pants and a light green puff sleeve shirt

hi there,

I’m  Clarice

Occupational therapist & medicare specialist helping practitioners understand policy, engage in advocacy, and own their value!

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