Highlights of the 2022 CMS Proposed Payment Rule

By:  OptimisPT Documentation and Compliance Team

On July 13, 2021 the Centers for Medicare and Medicaid Services (CMS) released their Proposed Payment Rule for Calendar Year 2022.  The full proposed rule, all 1,747 pages of it, can be found here.  We’ve taken the liberty of summarizing the key proposed changes that will directly affect outpatient rehab therapy services.  

Decrease in the 2022 Conversion Factor

In the proposed rule, the conversion factor is dropping from $34.89 in 2021 to $33.58 in 2022.  Some respite from this cut was achieved in 2021 secondary to congress providing funding of $3 billion to CMS allowing the proposed cut for 2021 to go from 9% to 3.3% secondary to the pandemic.  However, at this time, it does not appear this funding will be renewed.  Therefore, a decrease of $1.31 in the conversion factor is expected.  

RVU Increases

The RVU, or Relative Value Unit, is the value of a procedure relative to the value of all other procedures.  This is just part of the methodology that CMS uses to determine provider compensation.  CMS is proposing minimal increases in RVUs for some therapy CPT codes.  Most notably are increases for Occupational Therapy Evaluation codes (97165-97167).  This change is being proposed as a means to actually correct a miscalculation made by CMS regarding these codes in the past.  However, the APTA feels these potential increases in therapy RVUs will not be enough to offset the 3.75% decrease in the conversion factor resulting in decreased reimbursement for outpatient rehab therapy services.  Per CMS, the estimated impact of the changes being proposed in the Physician Fee Schedule to the total allowed charges by specialty leaves PT and OT with a net decrease of 2%.  While Speech Therapy is not specifically included in the CMS table, ASHA believes their decrease will be equal to the 2% decrease seen by PT and OT. (TABLE 123: CY 2022 PFS Estimated Impact on Total Allowed Charges by Specialty)  

15% Payment Reduction for PTA and OTA Services

As expected, it appears CMS will move forward with the 15% payment reduction for services billed with the CO or CQ modifier.  CMS is requiring those modifiers when a service is either partially or fully provided by a PTA or a COTA.  However, thanks to the advocacy of the APTA and the AOTA, CMS has agreed to tweak the definition of “in part”.  For example, the new proposed use would not require the application of the modifier when the PT provides enough minutes to constitute one unit but, the time provided by the PTA does not allow for another unit to be charged.  Previously, CMS was requiring the modifier be applied to the one unit to account for services being completed by the PTA.  Another scenario that CMS has updated occurs when the PT and the PTA each provide enough time for 2 units of a specific service.  Previously, CMS required the modifier be applied to both units.  CMS has since updated their stance on this scenario, requiring the modifier only be applied to the one unit being provided by the PTA. 


In the 2022 proposed rule, CMS does not permanently add PTs, OTs or SLPs to the list of approved telehealth providers, simply because they do not have the authority to do so.  The addition of any approved provider types must go through Congress.  Rehab therapy services can continue to be provided via telehealth as long as the Public Health Emergency (PHE) secondary to Covid-19 is active.  At this time, the PHE is set to expire on Oct 19th, 2021.  If the PHE is not extended, then for Medicare patients, PTs, OTs, and SLPs will no longer be allowed to provide treatment via telehealth. 

Possible Supervision Improvement for Private Practice

Currently, CMS requires direct supervision of PTAs by a PT when in the private practice setting.  This is different from the general supervision that is required in every other type of physical therapy setting. Direct supervision requires a visual and audio component as compared to general which requires only an audio component.  During the PHE, CMS is allowing direct supervision of a PTA to be completed through real-time, two-way audio and video technology.  Monitoring via this method includes the required visual component for direct supervision, being completed virtually, in addition to the audio component required for both direct and general supervision.  CMS is requesting feedback on whether or not to make this change permanent when the PHE is lifted.

Remote Therapeutic Monitoring Codes

CMS is considering adding a new family of codes to be used when non physician  healthcare professionals provide Remote Therapeutic Monitoring (RTM).  These codes would be similar to the Remote Physiological Monitoring (RPM) codes that can be billed by physicians.  However, secondary to how the RTM codes are constructed, they are considered “general medicine” codes which, per CMS, cannot be billed by PTs, OTs or SLPs.  CMS does recognize that there is value in allowing therapy providers to use these codes, therefore, they are seeking comment on how to better structure the codes to allow for rehab therapy use.

MIPS Proposed Changes

You may have heard that MIPS Value Pathways (MVPs) were coming in 2022.  CMS has decided to postpone the rollout of MVPs until 2023, with the traditional MIPS set to sunset after the performance year 2027.

Changes for the traditional 2022 MIPS specific to rehab therapists are proposed as follows:

  • Minimum Performance threshold (to avoid a penalty) increases from 60 to 75 
  • Exceptional Performance threshold is 89 points (2022 is the last year this is available)
  • +/- 9% maximum payment adjustment
  • Measure #154: Falls Risk Assessment to be removed
  • Data completion for quality measures remains 70% for 2022 (This is set to increase to 80% in 2023)
  • Quality measures scoring benchmarks:
    • Quality Measure Scoring – Scoring updates would be applied to measures that do not meet case minimum and data completeness requirements, and measures that do not have a benchmark.
    • Measures with a benchmark –  The 3-point floor would be removed for measures that can be scored against a benchmark. These measures would receive 1-10 points.
    • Measures without a benchmark – The 3-point floor would be removed for measures without a benchmark (except small practices). These measures would receive 0 points (small practices would continue to earn 3 points).
    • Measures that don’t meet case minimum requirements (20 cases) – The 3-point floor would be removed (except small practices).  These measures would earn 0 points (small practices would continue to earn 3 points).
    • New Quality Measures – A 5-point floor would be established for the first 2 performance periods for new Quality measures.
  • No additional bonus points will be given from reporting end-to-end electronic reporting, nor additional Outcome/High-priority measures beyond the required measures.  The small practice bonus will remain.
  • Redistributing Performance category weights for small practices: In cases where both the Cost and the Promoting Interoperability performance categories are reweighted, the Quality and Improvement Activities categories would be equally weighted at 50%.

Remember that the changes highlighted above are not yet finalized.   These are the proposed changes.  CMS will not be releasing the final rule until sometime in November 2021.  Therefore, there is time to let your voice be heard.  The APTA and AOTA will continue their advocacy efforts and are planning on creating template letters that can be used to send to CMS regarding these proposed changes.  In addition, you can also independently submit comments to the Federal Register site.   The comment submittal period ends September 13th, 2021.