Our experts have spent the past week digging into all 1,704 pages of CMS' proposed updates to the Physician Fee Schedule (PFS). Here are their three biggest takeaways:
1. CMS backpedals on E/M visit payment consolidation and provides PAs more autonomy
By Sarah Hostetter, Consultant, Physician Practice Roundtable and Eliza Campbell, Senior Analyst, Physician Practice Roundtable
In last year's proposed rule, CMS suggested dramatic changes to its payment and documentation policies for evaluation and management (E/M) visits. Previously, the coding for these routine office visits was broken out into five payment tiers for both new and established patients, and based on the time physicians spent with the patient and the level of medical complexity. CMS suggested collapsing all five tiers into one payment rate for new patients and one for established patients, and making it far easier for physicians to document the visits for reimbursement.
However, the American Medical Association and over 170 physician groups sent a letter of opposition to CMS over the measure, claiming it would make in-depth care financially unsustainable and lead to other unintended consequences. In response, CMS modified the proposal in their final rule to just collapse code levels 2 through 4 into one code for CY 2021, but maintain the level 5 code, which accounts for care provided to the most complex patients.
Yet in this new proposed rule for 2020, CMS has moved back to the five-tier system for established patients and suggested moving to a four-tier coding system for new patients. They've suggested adapting the revised E/M code definitions developed by the American Medical Association's CPT Editorial Panel and adopting the AMA's RUC-recommended payment rates (which were based on a survey of 50 different specialist types). These changes would take place beginning CY 2021. All told, these changes show the difficulty CMS has faced in trying to strike the right balance between reimbursing physicians for more complex care while also trying to reduce administrative burden. This recent move shifts the agency back towards the legacy system—proving how hard it can be for the CMS to enact sweeping changes.
CMS' also proposed modifying its regulations on physician supervision of physician assistants (PAs) with an aim toward allowing PAs to practice more broadly. This change is in line with the broader movement among state governments, payers, and provider organizations to enable PAs and other advanced practice providers (APPs) to practice more autonomously. Scope-of-practice and supervision requirements for PAs and other APPs are governed at the state level, and we're beginning to see states revise their laws to allow for more autonomous practice. By deferring to these state regulations, CMS is providing PAs with the flexibility needed to practice as providers and collaborate more closely with physicians and other members of the care team. In addition, by proposing that physicians, PAs, and APRNs be allowed to review and verify, rather than re-document, information recorded by other care team members, CMS is removing additional administrative burden that can be a barrier to team-based care. These two proposals combined will allow APPs to work at top-of-license and generate more value for provider organizations as well as foster more collaborative, team-based care—top priorities for many of the provider organizations we work with.
2. CMS wants more providers to use transitional care management
By Abby Burns, Senior Analyst, Population Health Advisor
CMS' adjustments to improve provider uptake of transitional care management (TCM) codes is in keeping with the agency's broader efforts to improve low-acuity care management (such as their recently announced Primary Cares Initiative). Essentially, CMS is trying to address the biggest grievance we hear around "fee-for-value" codes (like TCM, CCM, ACP, etc.), that the payment that organizations receive isn't worth the administrative burden they present. We've seen that TCM has demonstrated impact on reducing readmissions, mortality and total cost of care, but according to CMS, the code is still underutilized. To try to increase uptake, the proposed rule does two things:
- It limits billing restrictions. After re-evaluating the list of codes providers are ineligible to bill within the same 30-day period as TCM, CMS identified 14 codes that do not meaningfully overlap should therefore be removed; and
- It increases the work RVUs for both TCM codes (99495 and 99496). In 2018, the Relative Value Scale Update Committee (RUC), the body that recommends RVUs for medical services, recommended a slight RVU increase based on a standard resurvey.
Eliminating some of the billing restrictions and increasing the work RVUs of the TCM codes should help alleviate the predominant provider concerns to drive greater uptake.
3. CMS tries to streamline reporting in the QPP program
By Ye Hoffman, Consultant, Quality Reporting Roundtable and Julia Connell, Senior Analyst, Quality Reporting Roundtable
The updates to the Quality Payment Program (QPP) for performance year 2020 were largely expected, and build on policies that CMS has set in motion over the past few years. For example, the Merit-based Incentive Payment System (MIPS) program is designed to become more difficult over time, and the proposal reflects that aim by increasing the performance threshold required to avoid penalties to 45 points in 2020 from 30 points in 2019. The proposal also includes updates within each MIPS performance category for 2020, although without major changes to the structure and complexity of the program.
However, one proposed change is worth noting. CMS has consistently heard from providers that MIPS is overly complex and burdensome, and is aiming to address those concerns through a new framework called MIPS Value Pathways (MVPs) that would take effect in the 2021 performance year. MVPs would focus on a particular scope of practice and/or outcome, such as Major Surgery or Diabetes Prevention and Treatment, and establish sets of connected measures across the four MIPS performance categories.
This proposal is the biggest shift so far to streamline MIPS reporting requirements, and would shed some of the program's complexity. CMS intends to fully implement the MVP framework over the next three to five years to facilitate providers' movement into Alternative Payment Models (APMs), including greater access to CMS-provided performance feedback.
For providers who are poised to participate in the Advanced APM (APM) track in 2020, CMS is proposing small refinements to clarify other payer APM qualifications and to make sure that providers take on meaningful levels of risk. For example, CMS is proposing to revoke QP status for providers who terminate participation in an APM during a given performance year. This demonstrates that while CMS' ultimate goal is to encourage greater participation in the APM track, they're unwilling to compromise on the financial risk necessary to do so.
Public comment on the proposal is due September 27th, and we encourage everyone to weigh in on the future of the program.