United States: CMS Proposes Medicare Physician Fee Schedule Rates And Policies for CY 2020

The Centers for Medicare & Medicaid Services (CMS) has published its proposed Medicare physician fee schedule (PFS) rule for calendar year (CY) 2020. In addition to updating rates for physician services, CMS proposes changes to numerous other Medicare Part B policies. Highlights of the proposed rule include the following:

  • The proposed 2020 conversion factor (CF) is $36.0896, up slightly from the 2019 CF of $36.0391. CMS also proposes updates to work and practice expense relative value units (RVUs) for numerous new, revised, and potentially misvalued codes.
  • CMS solicits feedback on contractor reports regarding the number and level of postoperative visits for surgical procedures. The data is intended to inform potential revisions to the global surgical package.
  • CMS requests comments on new opportunities for unspecified bundled payment rates for PFS services that are furnished together. Such bundles might include per-beneficiary payments for multiple services or condition-specific episodes of care.
  • CMS proposes additional updates to evaluation and management (E/M) visit coding and payment policies for 2021 to align withCPT Editorial Panel changes. CMS notes that the E/M changes would provide the greatest RVU increase to specialties that bill higher level established patient visits, while specialties that do not generally bill office/outpatient E/M visits, because of budget neutrality, could see large payment decreases. For instance, CMS estimates that endocrinology charges could increase 16% and rheumatology charges could rise by 15%, while radiology charges would fall by 8% and ophthalmology charges would drop 10% as a result of the proposed E/M policies if implemented for CY 2021. CMS adds that the 2021 implementation date allows "a year of preparatory time and time for potential refinement over the next year as we take into account any feedback from stakeholders on these proposed changes."
  • CMS proposes to replace the current Medicare requirement for general physician supervision of physician assistants (PAs), including the immediate availability of the supervising physician to the PA for consultation, with medical direction and appropriate supervision as provided by State law. In the absence of State law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA's approach to working with physicians in furnishing their professional services.
  • CMS proposes to streamline documentation requirements by allowing the physician, PA, or advanced practice registered nurse who furnishes and bills for his or her professional services to review and verify — rather than fully re-document — information included in the medical record by physicians, residents, nurses, students or other members of the medical team. This principle would apply to all Medicare-covered services paid under the PFS.
  • CMS continues to implement a statutory requirement that modifiers be reported to identify certain therapy services that are furnished in whole or in part by physical therapy (PT) and occupational therapy assistants (OTA), beginning January 1, 2020. CMS has adopted a de minimis standard under which a service is considered to be furnished in whole or in part by a PTA or OTA when more than 10% of the service is furnished by the PTA or OTA. CMS proposes to make the 10% calculation based on the respective therapeutic minutes of time spent by the therapist and the PTA/ OTA, rounded to the nearest whole minute. Beginning January 1, 2022, claims that contain a therapy assistant modifier will be paid at 85% of the otherwise applicable payment amount.
  • CMS proposes to establish bundled payments for opioid use disorder treatment services furnished by opioid treatment programs.
  • CMS proposes changes to Open Payments reporting requirements, including: codifying a statutory expansion of the definition of a covered recipient to include PAs, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives; adding Debt Forgiveness, Long-Term Medical Supply or Device Loan, and Acquisitions to the "nature of payment" categories; consolidating medical education program categories; and standardizing data reporting requirements for drugs, devices, biologicals, and medical supplies.
  • CMS requests comments on a series of potential changes to the physician self-referral (Stark Law) advisory opinion process.
  • CMS proposes a number of changes to the Quality Payment Program (QPP). Notably, CMS proposes establishing new Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) beginning in the 2021 performance period to allow clinicians to report on a smaller set of outcomes-based, specialty-specific measures. The QPP proposals are detailed in a CMS fact sheet.
  • Other topics addressed by the rule include, among many others:documentation of beneficiary consent for cost sharing associated with communication technology-based services; collection of ground ambulance cost data; Medicare Shared Savings Program quality reporting requirements; and payment for chronic care management, transitional care management, and principal care management services.

CMS will accept comments on the proposed rule through September 27, 2019.

This article is presented for informational purposes only and is not intended to constitute legal advice.

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