Society Advocacy Helps PALTC Clinicians as CMS Releases Medicare Physician Fee Schedule and Quality Payment Program Final Rules

On November 1, 2019, the Centers for Medicare & Medicaid Services (CMS) released the CY 2020 Medicare Physician Fee Schedule and Quality Payment Program (QPP) final rules. Below is a summary of some of the policies CMS finalized.

Physician Fee Schedule (PFS)

CY 2020 PFS Conversion Factor

CMS is finalizing a series of standard technical proposals involving practice expense, including implementation of the second year of the market-based supply and equipment pricing update, and standard rate setting refinements to update premium data involving malpractice expense and geographic practice cost indices (GPCIs).

With the budget neutrality adjustment to account for changes in Relative Value Units (RVUs), as required by law, the finalized CY 2020 PFS conversion factor is $36.09, a slight increase of $0.05 above the CY 2019 PFS conversion factor of $36.04.

Medicare Telehealth Services

For CY 2020, CMS is adding the following codes to the list of telehealth services: HCPCS codes G2086, G2087, G2088, which describe a bundled episode of care for treatment of opioid use disorders.

Evaluation and Management (E/M) Services

CMS is aligning E/M coding with changes adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits. The Society participated in the workgroup that developed these recommendations. The CPT changes retain five levels of coding for established patients, reduce the number of levels to four for office/outpatient E/M visits for new patients, and revise the code definitions. The CPT code changes also revise the times and medical decision-making process for all of the codes and require performance of history and exam only as medically appropriate. The CPT code changes also allow clinicians to choose the E/M visit level based on either medical decision-making or time.

CMS is adopting the AMA Specialty Society Relative Value Scale Update Committee (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 will increase payment for office/outpatient E/M visits. The RUC recommendations reflect a robust survey approach by the AMA, including surveying more than 50 specialty types, and demonstrating that office/outpatient E/M visits are generally more complex and require additional resources for most clinicians.

CMS is also strengthening the Medicare-specific payment for office/outpatient E/M visits for primary care and non-procedural specialty care that we finalized in the CY 2019 PFS final rule. It simplified this payment by using a single add-on code describing the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. This will be implemented in CY 2021.

Click here for more information on the AMA E&M office visit revision.

Physician Supervision Requirements for Physician Assistants (PAs)

CMS is updating its regulation on physician supervision of PAs to give PAs greater flexibility to practice more broadly in the current health care system in accordance with state law and state scope of practice. In the absence of any state rules, CMS is finalizing a revision to the current supervision requirement to clarify that physician supervision is a process in which a PA has a working relationship with one or more physicians to supervise the delivery of their health care services. Such physician supervision is evidenced by documenting the PA’s scope of practice and indicating the working relationship(s) the PA has with the supervising physician(s) when furnishing professional services.

Review and Verification of Medical Record Documentation

CMS finalized broad modifications to the documentation policy so that physicians, physician assistants, and advanced practice registered nurses (APRNs - nurse practitioners, clinical nurse specialists, certified nurse-midwives, and certified registered nurse anesthetists) can review and verify (sign and date), rather than re-document, notes made in the medical record by other physicians, residents, medical students, physician assistants, and APRN students, nurses, or other membes of the medical team. 

Care Management Services

CMS is increasing payment for transitional care management (TCM) services, which are care management services provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays.

CMS is creating a Medicare-specific code for additional time spent beyond the initial 20 minutes allowed in the current coding for chronic care management (CCM) services, which are services provided to beneficiaries with multiple chronic conditions over a calendar month.

Recognizing that clinicians across all specialties manage the care of beneficiaries with chronic conditions, CMS also is creating new coding for principal care management (PCM) services, for patients with only a single serious and high-risk chronic condition.

Quality Payment Program

MIPS Value Pathways (MVPs)

The MVP approach responds to some of the recommendations made to CMS by the AMA after significant consultation with specialty and state medical societies about opportunities to improve the Merit-based Incentive Payment System (MIPS) and move away from the current check-the-box reporting requirements. Physicians in MVPs would focus their MIPS participation on a set of measures tailored to an episode of care or condition starting in the 2021 performance period. The MVP framework would also provide enhanced data and feedback to physicians.

While CMS did not finalize specifics about the MVP, it emphasized that it is developing the MVP to reduce physician burden associated with the MIPS program and will work with specialty societies to further develop this approach so that it’s relevant to the specific episodes of care they provide and their patient population. One of the most concerning aspects of the MVP framework in the proposed rule was an indication it would be mandatory, which CMS has appeared to back away from and will make a determination about in the future. CMS expects MVPs will be available starting in 2021 and more details will be included in future rulemaking.

Performance Category Weights – No changes from 2019. Due to Society advocacy, CMS elected not to finalize an increase to the Cost category of the MIPS program. The Society has long shared concerns that this category unfairly treats clinicians who take care of high-cost complex patients such as those in skilled nursing facilities. The Society welcomes CMS’ decision not to increase this category at this time.

Alternative Payment Models (APMs)

CMS finalized establishing a new definition of Aligned Other Payer Medical Home models, consistent with the existing financial risk requirements for Medicaid medical homes and modifying the marginal financial risk requirements for Other Payer APMs. The final rule includes an estimate that between 210,000 and 270,000 clinicians will become Qualifying APM Participants in 2020 and receive an APM incentive payment in 2022.

Please visit this website to view the CY 2020 Physician Fee Schedule and Quality Payment Program final rule (CMS-1715-F).