On July 29, 2019, CMS released the Calendar Year (CY) 2020 Physician Fee Schedule (PFS) proposed rule (the Proposed Rule). The Proposed Rule updates payment policies, payment rates, and quality provisions for services furnished under the PFS. A display copy of the Proposed Rule is available here and the CMS fact sheet available here. The Proposed Rule is scheduled to be published in the Federal Register on August 14, 2019. Comments are due by September 27, 2019.
Payment Updates
Rate Setting & Conversion Factor
PFS payments are based on the relative resources typically required to furnish the service, also known as Relative Value Units (RVUs). These RVUs become payment rates through the application of a conversion factor. To account for budget-neutrality adjustments for changes in RVUs, the proposed CY 2020 PFS conversion factor is $36.09, a slight increase from the CY 2019 PFS conversion factor of $36.04.
Additionally, CMS proposes a series of technical improvements involving practice expense, including pricing updates to market-based supply and equipment pricing in the second year, and refinements to standard rates to reflect premium data involving malpractice expense and geographic practices cost indices (GPCIs).
Evaluation and Management Services Payments
For CY 2020, CMS proposes to align CMS Evaluation and Management (E/M) coding with changes set forth by the CPT Editorial Panel for office/outpatient E/M visits. The proposal will retain 5 levels of coding for established patients but reduce the number of levels to 4 for new patients and involves revisions to code definitions. The proposal also includes revisions to the times and medical decision-making process for all codes and requires the performance of a patient history and exam only as medically appropriate. These new changes will permit clinicians to choose the E/M visit level based on either medical decision making or time.
For CY 2021, CMS proposes to adopt American Medical Association RVS Update Committee (AMA RUC) recommended values for office/outpatient E/M visits codes and permit a new add-on CPT code for prolonged service time. CMS is also soliciting information and feedback from the public regarding the consolidation of the Medicare-specific add-on code for office/outpatient E/M visits for primary care and non-procedural specialty care, which was finalized in the CY 2019 PFS Final Rule, into a single code describing all work related to visits that are part of ongoing, comprehensive primary care and/or visits related to a patient’s ongoing care for a chronic condition.
Bundled Payments Under the PFS for Substance Use Disorders
In response to comments received to the CY 2019 PFS proposed rule, CMS is now proposing to create new coding and payment for bundled episodes of care for management and counseling for opioid use disorder (OUD). The new proposed codes include overall management, care coordination, individual and group psychotherapy, and substance use counseling. CMS is also seeking comment on bundles for other substance use disorder services and the use of medication-assisted treatment (MAT) in emergency department settings to determine whether CMS should propose separate payments for such services in the future.
Care Management Services
Among other proposals relating to Care Management Services, CMS proposes increasing payment for transitional care management, a care management service provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays. CMS is also proposing a set of Medicare-developed Healthcare Common Procedure Coding (HCPC) G-codes for certain Chronic Care Management (CCM) services. CCM services provide care coordination to beneficiaries with multiple chronic conditions over a calendar month service period. CMS proposes replacing certain 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.
CMS also proposes creating new coding for principal care management services, which would pay clinicians for providing care management for patients who have a single serious, high-risk condition.
Telehealth Services
In the Proposed Rule, CMS proposes adding certain HCPCS codes to the list of telehealth services covered by Medicare. These codes include GYYY1, GYYY2, and GYYY3, which describe a bundled episode of care for treatment of opioid use disorders.
Therapy Services
Beginning in January 1, 2020, the therapy services modifiers listed in the CY 2019 PFS final rule will be required by statute to be reported on all claims. Those modifiers identify therapy services that are furnished in whole or in part by physical therapy and occupational therapy assistants and set a de minimis 10 percent standard for when such modifiers will apply to specific services. CMS is now proposing a policy to implement these modifiers and the 10 percent de minimis standard.
Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs
Under Section 2005 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, CMS is required to establish a new Medicare Part B benefit for OUD treatment services, including medications for MAT furnished by opioid treatment programs (OTPs). To fulfill this statutory requirement, CMS specifically proposes:
- Definitions of OTP and OUD treatment services;
- Enrollment policies for OTPs;
- Methodology and estimated bundled payment rates for OTPs that vary by the medication used to treat OUD and service intensity, and by full and partial weeks;
- Adjustments to bundled payment rates for geography and annual updates;
- Flexibility to deliver the counseling and therapy services described in the bundled payments via two-way interactive audio-video communication technology as clinically appropriate; and
- Zero beneficiary copayment for a limited period of time.
The SUPPORT act requires CMS to implement this benefit beginning January 1, 2020.
Open Payments and Medicare Shared Savings Programs
Open Payments Program
CMS proposes several changes to the Open Payments Program including (1) expanding the definition of “covered recipient;” (2) modifying payment categories; and (3) standardizing data on reported medical devices. These minor changes are aimed at reducing the associated burden of reporting under the program while clarifying and making the data more useful to the public.
Medicare Shared Savings
CMS seeks comments on how to potentially align the Medicare Shared Savings Program (MSSP) quality performance scoring methodology more closely with the Merit-based Incentive Payment System (MIPS) quality performance scoring methodology. Furthermore, CMS proposes refining the MSSP measure set by (1) removing one measure and adding another to the CMS Web Interface, and (2) reverting one measure to pay-for-reporting due to substantive change made by measure owners.
Physician Supervision Requirements for Physician Assistants
CMS proposes modifications to CMS’s regulation of physician supervision of physician assistants (PAs). Specifically, in the absence of state law governing physician supervision of PAs, the physician supervision required for PA services must be evidenced by documentation in the medical record of the PA’s approach to working with physicians in furnishing services.
Review and Verification of Medical Record Documentation
In the Proposed Rule, CMS proposes broad modifications to the current medical record documentation policy so that physicians, PAs, nurse practitioners, clinical nurse specialists, and certified nurse-midwives may review and verify (sign and date) notes made in the medical record by other physicians, residents, nurses, students, or other members of the medical team, as opposed to completely re-documenting these notes, as the current rule requires. These proposed modifications come as a response to feedback CMS received from clinicians in response to CMS’ “Patients Over Paperwork” initiative request for information. Stakeholders argued that undue burden is created when physicians and other practitioners must re-document notes entered into the medical record by other members of the medical team.
Other Provisions
Ambulance Services and Ground Ambulance Data Collection System
CMS proposes to clarify that there is no CMS-prescribed form for physician certification statements (PCSs) for ambulance transports. CMS also proposes to grant ambulance suppliers and providers increased flexibility regarding who may sign a non-PCS by allowing licensed practical nurses, social workers, and case managers as staff members who may sign the non-PCS if the provider or supplier is unable to obtain the attending physician’s signature within 48 hours of the transport.
Also, in accordance with the Bipartisan Budget Act of 2018, CMS proposes a sampling methodology to identify ground ambulance organizations for reporting each year through 2024 and not less than every three years after 2024. CMS also proposes reducing payments that would otherwise be made to a ground ambulance organization that is identified for reporting but fails to sufficiently submit data. A ground ambulance organization will be able to request a hardship extension that would all the organization to avoid the payment reduction.
Stark Advisory Opinion Process
In 2018, CMS issued a request for information to gather public input on how to address unnecessary burden created by the federal physician self-referral law (the Stark Law). Many stakeholders urged CMS to update the regulations governing its advisory opinion process to reduce provider burden and uncertainty. CMS is now soliciting additional comments regarding potential changes to its advisory opinion process, which the agency expects to address in a separate rulemaking.
