On Friday, November 1, 2019 the Centers for Medicare and Medicaid Services (CMS) released the 2020 Medicare Physician Fee Schedule (PFS) final rule, which includes updates to the Quality Payment Program (QPP), and the 2020 Medicare Hospital Outpatient Prospective Payment System final rule. The final rules are effective on January 1, 2020.
Medicare Physician Fee Schedule 2020 Final Rule
The finalized Calendar Year (CY) 2020 PFS conversion factor is $36.09, up slightly from the CY 2019 PFS conversion factor of $36.04. Below are some of the key changes for CY 2020 and CY 2021.
CMS Reported Estimates of Payment Impact on PFS Services:
- Hematology/Oncology 0%
- Nurse Practitioner 0%
- Physician Assistant 0%
- Radiation Oncology 0%
- Rheumatology 0%
Documentation – Evaluation and Management (E/M) Services for CY 2020
- Physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives can review and verify (sign and date), rather than re-document, notes made in the medical record about the patient’s chief complaint and history by other physicians, residents, nurses, students, or other members of the medical team.
- This will also apply to regulations for teaching physicians, physicians, PAs and ARPNs, adding flexibility for these clinicians in all settings.
E/M Services for CY 2021 – CMS will:
- Align 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 CPT coding changes retain 5 levels of coding for established patients, reduces the number of levels to 4 for office/outpatient E/M visits for new patients (deleting CPT 99201), and revise the code definitions.
- Adopt documentation requirements included in the CPT Editorial Panel’s revisions to the code set in 2021.
- Allow providers to select a visit code level based on time (the typical time for the reported code) or medical decision-making (MDM) and eliminate the history and physical exam as required elements to select a code level.
- Adopt AMA CPT code 99XXX Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)).
- Finalize new HCPCS code GPC1X Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex condition, to better describe 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.
- Adopt the AMA Specialty Society Relative Value Scale Update Committee (RUC) recommended values for the office/outpatient E/M visit codes for CY 2021, resulting in a payment increase in 2021 for these services. increased in 2021.
Physician Supervision Requirements for Physician Assistants (PAs)
- PA must furnish their professional services in accordance with state law and state scope of practice rules for PAs in the state in which the PA’s professional services are furnished. Any state laws or state scope of practice rules that describe the required practice relationship between physicians and PAs, including explicit supervisory or collaborative practice requirements, describe a form of supervision for purposes of section 1861(s)(2)(K)(i) of the Act.
- For states with no explicit state law or scope of practice rules regarding physician supervision of PA services, 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 at the practice level the PA’s scope of practice and the working relationships the PA has with the supervising physician/s when furnishing professional services.
Care Management Services for CY 2020 – CMS finalized:
- Increased payment for transitional care management (TCM) services.
- A new Medicare-specific code for additional time spent beyond the initial 20 minutes allowed in the current coding for chronic care management (CCM) services:
- G2058 (Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).
- Two new codes for principal care management (PCM) services, for patients with only a single serious and high-risk chronic condition:
- G2064 – 30 minutes of physician time per month – one complex chronic condition (Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting atleast 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities)
- G2065 – 30-minutes of clinical staff time per month – one complex chronic condition (Comprehensive care management for a single high-risk disease services, e.g., Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities)
2020 Quality Payment Program Performance Period
CMS is increasing the performance threshold from 30 points in 2019 to 45 points, and the exceptional performance threshold from 75 points in 2019 to 85 points in 2020.
CMS did not finalize the proposed changes in the quality and cost category weights. The performance category weights will remain as they are in 2019: Quality performance category is weighted at 45%, Cost performance category is weighted at 15%, Promoting Interoperability performance category is weighted at 25%, and Improvement Activities performance category is weighted at 15%.
CMS also announced a number of changes for the four performance categories:
Quality Performance Category changes include:
- Increasing the data completeness threshold to 70%;
- Continuing to remove low-bar, standard of care, process measures;
- Addressing benchmarking for certain measures to avoid potentially incentivizing inappropriate treatment;
- Focusing on high-priority outcome measures, and
- Adding new specialty sets (Speech Language Pathology, Audiology, Clinical Social Work, Chiropractic Medicine, Pulmonology, Nutrition/Dietician, and Endocrinology).
Cost Performance Category changes include:
- Adding 10 new episode-based measures to continue expanding access to this performance category, and
- Revising the existing Medicare Spending Per Beneficiary Clinician and Total Per Capita Cost measures.
Improvement Activities Performance Category changes include:
- Reducing barriers to patient-center medical home designation by removing specific examples of entity names of accreditation organizations or comparable specialty practice programs;
- Increasing the participation threshold for group reporting from a single clinician to 50% of the clinicians in the practice needing to perform the same improvement activity; finalizing their proposal with modification, such that instead of requiring that a group must perform the same activity for the same continuous 90 days in the performance period as proposed, CMS is requiring that a group must perform the same activity during any continuous 90-day period within the same performance year;
- Updating the Improvement Activity Inventory and establishing factors for consideration for removal; and
- Concluding the CMS Study on Factors Associated with Reporting Quality Measures.
Promoting Interoperability Performance Category changes include:
- Including the Query of Prescription Drug Monitoring Program (PDMP) measure as an optional measure (available for bonus points);
- Removing the Verify Opioid Treatment Agreement measure;
- Reducing the threshold for a group to be considered hospital-based (Instead of 100% of clinicians, more than 75% of the clinicians in a group must be a hospital-based individual MIPS eligible clinician in order for the group to be excluded from reporting the measures under the Promoting Interoperability performance category and to have this category reweighted to zero.);
- Beginning with PY 2019, requiring a “yes/no” response instead of a numerator and denominator for the optional Query of PDMP measure;
- Beginning with PY 2019, redistributing the points for the Support Electronic Referral Loops by Sending Health Information measure to the Provide Patients Electronic Access to Their Health Information measure (if an exclusion is claimed).
Additional information and QPP resources are available on the QPP Website at https://qpp.cms.gov
Medicare Physician Fee Schedule Final Rule
Medicare Physician Fee Schedule Final Rule Fact Sheet
Quality Payment PrograM
Medicare Hospital Outpatient Prospective Payment System Final Rule
2020 Hospital Outpatient Prospective Payment System (OPPS) Final Rule:
- Medicare’s OPPS rates will increase by a net 2.6% in 2020.
- CMS declined to finalize their proposal requiring hospitals to publicize a list of standard charges. Instead, CMS will summarize and respond to concerns about hospitals price transparency for shoppable services in forthcoming final rules.
- CMS finalized the second of a two-year phase in of the site-neutral rate, which is 40% of the OPPS rate, to cap payment for off-campus hospital clinic visits at a rate equivalent to the physician fee schedule rate. This is despite the lawsuit that saw a federal judge rule against CMS’ site neutral payment policy.
- CMS will continue the 22.5% payment rate cuts for some drugs under the 340B program, in spite of a federal judge ruling that the 340B drug reimbursement rate that Health and Human Services set in the 2019 Outpatient Prospective Payment System (OPPS) rule is unlawful.
- At the same time, CMS acknowledged the court ruling, which it has appealed, and solicited comments for a potential remedy in the event of an unfavorable decision.
Medicare Hospital Outpatient Prospective Payment System Final Rule Fact Sheet
We will provide an in-depth review of all of the most pertinent items in these final rules in the next edition of the Oplinc Best Practices Review newsletter.