CMS Releases 2020 Physician Fee Schedule and Quality Payment Program Proposed Rules

On July 29, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2020. Also released was CMS’ proposed policies for the 2020 performance year of the Quality Payment Program (QPP). The Society will continue to review the rules and submit comments in September.

Here are some highlights of the PFS:

CY 2020 PFS Conversion Factor: $36.0896

Proposed 2020 Nursing Facility Codes RVUs and Payment Rates

Payment for Evaluation and Management (E/M) Services

CMS is proposing to align E/M coding with changes laid out by the CPT Editorial Panel for office/outpatient E/M visits effective January 1, 2021. The CPT coding changes retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients, and revise the code definitions. The CPT changes also revise the times and medical decision-making process for all of the codes and requires performance of history and exam only as medically appropriate. In addition, the CPT code changes allow clinicians to choose the E/M visit level based on either medical decision-making or time. 

CMS is proposing to adopt the AMA RUC-recommended values for the office/outpatient E/M visit codes for CY 2021 and the new add-on CPT code for prolonged service time. The AMA RUC-recommended values would increase payment for office/outpatient E/M visits. The RUC recommendations reflect a robust survey approach by the AMA, including surveying over 50 specialty types to demonstrate that office/outpatient E/M visits are generally more complex and require additional resources for most clinicians. The Society participated in the survey process and thanks all of its members who took the time to fill out these surveys. These proposed policies show the importance of the engagement of Society members in shaping national health policy.

With all the positive changes to documentation and payment in the ambulatory primary care space, evaluation and management services in the nursing facility continue to be overlooked despite the importance of these services to value-based medicine. The Society plans to address this issue in the near future.

Transitional Care Management (TCM)

CMS is proposing to increase payment for TCM, which is a care management service provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays. CMS is proposing to allow TCM codes to be billed concurrently with a greater number of codes, including:

• Prolonged Services without Direct Patient Contact (99358, 99359)
• Home and Outpatient International Normalized Ratio (INR) Monitoring Services (93792,93793,90960,90961,90962, 90966, 90970)
• End Stage Renal Disease Services (patients who are 20+ years old) (90960-62, 90966, 90970)
• Interpretation of Physiological Data (99091)
• Complex Chronic Care Management Services (99487, 99489)
• Care Plan Oversight Services (G0181, G0182)

CMS is seeking comment on whether the newest CPT code in the chronic care management services family (CPT code 99491 for CCM by a physician or other qualified health professional, established in 2019) overlaps with TCM or should be reportable and separately payable in the same service period.

Telehealth Services

CMS retained the 30-day limit on skilled nursing facility visits for telehealth services. For CY 2020 CMS did propose adding the following codes to the list of telehealth services: HCPCS codes GYYY1, GYYY2, and GYYY3, which describe a bundled episode of care for treatment of opioid use disorders.

Chronic Care Management (CCM) Services

CMS is proposing a set of Medicare-developed HCPCS G codes for certain CCM services. CCM is a service for providing care coordination and management services to beneficiaries with multiple chronic conditions over a calendar month service period. CMS is proposing to replace a number of the CCM codes with Medicare-specific codes to allow clinicians to bill incrementally to reflect additional time and resources required in certain cases and better distinguish complexity of illness as measured by time. The first G Code would describe the initial 20 minutes of clinical staff time, and the second G code would describe each additional 20 minutes thereafter. CMS intends to use temporary G codes (GCCC1, GCCC2) instead of code 99490 until the CPT Editorial Panel can consider revisions to the current set of CPT codes.

Complex CCM Services (CPT code 99487 and 99489, GCCC3 and GCCC4)

CMS proposes to adopt two new G codes that would be used for billing under the PFS instead of CPT codes 99487 and 99489, and that would not include the service component of substantial care plan revision. CMS believes it is not necessary to explicitly include substantial care plan revision because patients requiring moderate to high complexity medical decision-making implicitly need and receive substantial care plan revision. CMS says that the service component of substantial care plan revision is potentially duplicative with the medical decision-making service component and, therefore, believes it is unnecessary as a means of distinguishing eligible patients. Instead of CPT code 99487, CMS proposes to adopt HCPCS code GCCC3 and instead of code 99489 it proposes to adopt GCCC4. These will be temporary until the CPT Editorial Board considers revisions to the current code.

Other Care Management Revisions

CMS is also proposing to adjust certain billing requirements and elements of the care planning services. CMS is proposing to eliminate the phrase “community/social services ordered, how the services of agencies and specialists unconnected to the practice will be directed/coordinated, identify the individuals responsible for each intervention” and insert the phrase “interaction and coordination with outside resources and practitioners and providers.” CMS feels that simpler language would describe the important work of interacting and coordinating with resources external to the practice.

Some Highlights of the Quality Payment Program Proposed Rule Include:

MIPS Value Pathways (MVPs)

CMS is proposing to apply a new MVPs framework to future proposals beginning with the 2021 MIPS Performance Year. MVPs would utilize sets of measures and activities that incorporate a foundation of promoting interoperability and administrative claims-based population health measures and layered with specialty/condition-specific clinical quality measures to create both more uniformity and simplicity in measure reporting. The MVP framework will also connect quality, cost, and improvement activity performance categories to drive toward value; integrate the voice of patients; and reduce clinician barriers to movement into Advanced APMs. Further, the MVP framework would reduce the number of performance measures and activities clinicians may select. Ultimately, CMS believes this would decrease clinician burden and improve performance data quality, while still accounting for different types of specialties and practices. The Society has participated in a number of meetings over this last year to craft proposals for CMS and is encouraged that the agency is listening to the Society in this proposal.

MIPS Category Proposed Changes:

• Reduce the Quality performance category weight to 40% in 2020, 35% in 2021, and 30% in 2022
• Increase the Cost performance category weight to 20% in 2020, 25% in 2021, and 30% in 2022

For the Improvement Activities performance category, we are proposing the following changes:

• Modification of the definition of a rural area
• Removal of criteria for patient-centered medical home designation that a practice must have received accreditation from one of four accreditation organizations that are nationally recognized or comparable specialty practice that has received the NCQA Patient-Centered Specialty Recognition
• Increasing the participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice
• Updating the Improvement Activity Inventory and establishing criteria for removal in the future
• Concluding the CMS Study on Factors Associated with Reporting Quality Measures

CMS did not propose significant changes to the Promoting Interoperability performance category. However, they are seeking comment on several key areas:

• Potential opioid measures for future inclusion in the Promoting Interoperability performance category
• Development of potential measures that are based on existing NQF and CDC efforts that measure the clinical and process improvements specifically related to the opioid epidemic
• A metric to improve efficiency of providers within EHRs
• Issues related to the standards-based API criterion in the ONC 21st Century Cures Act proposed rule with the goal of establishing an alternative measure under the Provider to Patient Exchange that would require providers to give patients their complete data contained within an EHR
• Integration of patient-generated health data (PGHD) into EHRs using CEHRT
• Engaging in activities that promote the safety of the EHR

SNF Specialty Measure Set

CMS retains the skilled nursing facility specialty measure set. They have proposed adding the Adult Immunization Status measure and removing the Preventive Care and Screening Influenza Immunization and Zoster (Shingles)Vaccination measures.

Other key proposals for 2020 performance year of the Quality Payment Program include:

• Increasing the performance threshold from 30 points to 45 points
• Increasing the data completeness threshold for the quality data that clinicians submit
• Updating requirements for Qualified Clinical Data Registry (QCDR) measures and the services that third-party intermediaries must provide (beginning with the 2021 performance period)
• Revising the specifications for the Total Per Capita Cost (TPCC) and Medicare Spending Per Beneficiary Clinician (MSPB Clinician) measures

For more information:

• Click here for a CMS Fact Sheet on the 2020 Physician Fee Schedule Proposed Rule
• Click here for a CMS Fact Sheet on the 2020 Quality Payment Program Proposed Rule
• Click here for Full Proposed Rule