July 30, 2019

CMS on Monday issued a proposed rule to update the Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) for calendar year (CY) 2020, which includes proposals intended to reduce physicians' administrative burdens and promote value-based care.

Sept. 3 webconference: Register now for our deep dive into the MPFS proposed rule

CMS in a release said the proposed rule includes changes "aimed at reducing burden, recognizing clinicians for the time they spend with patients, removing unnecessary measures, and making it easier for them to be on the path towards value-based care." CMS continued, "This proposed rule builds on the Trump administration's efforts to establish a patient-driven health care system that focuses on better health outcomes, and is projected to save 2.3 million hours per year in burden reduction."

Proposed changes to the fee schedule

CMS in a fact sheet said the proposed rule would, for the second year, implement pricing updates based on market-specific supply and equipment prices, malpractice expenses, and geographic-based practice costs.

Overall, CMS said the proposed CY 2020 PFS conversion factor would be $36.09, a slight increase above the CY 2019 PFS conversion factor of $36.04.

Cheat sheet: How CMS calculates PFS payments

CMS backpedals on changes to E/M visit payments

CMS in its release said the proposed rule also aims to build on changes the agency finalized last year to streamline billing for evaluation and management (E/M) visit codes, which are a generic set of codes that most physicians use to bill routine visits.

In last year's proposed rule, the agency had suggested collapsing the five-tier payment system for E/M visit—a move that drew pushback from many physician groups who worried the changes could lead to unintended consequences. In response, CMS in last year's final rule maintained a separate level 5 code, accounting for care provided to the most complex patients.

Understand the E/M changes in the 2019 final rule

Under CMS' proposed rule for 2020, the agency moved back to the five-tier system for established patients and suggested moving to a four-tier coding system for new patients. It suggested adapting the revised E/M code definitions developed by the American Medical Association's (AMA) CPT Editorial Panel beginning Jan. 1, 2021. These CPT code changes would revise the time and decision-making guidelines for each level, and they would require documentation of patient history and a medical exam only when clinically appropriate. They would allow physicians to select the appropriate level of visit based on the extent of decision-making in the exam or based on time spent with the patient.

CMS also proposed adopting the AMA's RUC-recommended payment rates, which were set after a survey of over 50 specialty types showed that "office/outpatient E/M visits are generally more complex and require additional resources for most clinicians." With this change, CMS would not pay a single blended rate for code level 2 through 4, but instead would make payments based on each level of service.

CMS under last year's final rule also implemented a new "extended visit" code that allowed physicians to receive higher payment rates for spending additional time with patients whose visits are coded at level 2 through 4. Under the new proposed rule, CMS proposed consolidating this add-on code for primary care management that requires comprehensive care, as well as for non-procedural specialty care that is part of treating complex chronic conditions.

Those proposed changes would not apply to global surgery codes. CMS in the proposed rule asked stakeholders to comment on changes to global surgery coding.

CMS proposes increasing payment for transitional care management and expanding the scope of PAs

Further, CMS proposed increasing Medicare transitional care management payments to recognize clinicians for the time spent managing a patient's care after the patient leaves the hospital. In an effort to "ensur[e] proper follow-up and continuity of care for patients," the agency for the first time proposed paying clinicians for care management services for patients who have a single high-risk medical condition, such as diabetes or high blood pressure. CMS also proposed paying clinicians for time spent on care management activities for patients with multiple chronic conditions.

Webconference: How to manage your care transition opportunities

In addition, CMS proposed modifying its regulations on physician supervision of physician assistants (PAs) with an aim toward allowing PAs to practice more broadly, in accordance with state scope-of-practice and other laws. CMS in the fact sheet said, "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 services."

CMS in the fact sheet said the proposed rule also contains "broad modifications" to documentation policies that stakeholders have said require clinicians to re-document notes that already have been documented by other members of a patient's medical team. CMS said those modifications would allow "physicians, [PAs], nurse practitioners, clinical nurse specialists, and certified nurse-midwives" to "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" instead of re-documenting them.

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CMS in the proposed rule also requested public comments on expanding bundled payments under PFS.

CMS proposes raising the performance threshold for QPP

According to a fact sheet, CMS also proposed increasing the minimum number of points clinicians must receive to avoid a negative payment adjustment under QPP's Merit-based Incentive Payment System (MIPS) from 30 points in 2019 to 45 points in 2020, and 60 points in 2021.

In addition, CMS proposed increasing "the additional performance threshold for exceptional performance to 80 points in 2020 and to 85 points in 2021." CMS said its goal is to meet Congress' requirement to set the QPP performance threshold at the mean score of all clinicians in the previous year.

CMS also proposed:

  • Increasing the weight of MIPS' cost performance category to 20% in 2020, 25% in 2021, and 30% in 2022; and
  • Reducing the weight of MIPS' quality performance category to 40% in 2020, 35% in 2021, and 30% in 2022.

CMS in the fact sheet said it proposed those changes "to create better value and to gradually work toward equal weighting which is required by law beginning with the sixth year of the program."

Your MIPS toolkit

The agency said it also is proposing changes to refine MIPS' reporting measures and to establish new requirements for MIPS performance categories that must be supported by health IT vendors, qualified clinical data registries, and qualified registries. CMS also proposed requiring the federal government to publicly report aggregate MIPS data.

In addition, CMS proposed implementing a new conceptual framework for MIPS, called MIPS Value Pathways (MVPs), that would take effect after the 2021 performance period. CMS said the new framework "would move MIPS from its current state, which requires clinicians to report on many measures across the multiple performance categories, such as quality, cost, promoting interoperability, and improvement activities, to a system in which clinicians will report much less."

According to CMS, clinicians under MVPs would report on a reduced set of measures that are:

  • More closely aligned with alternative payment models (APMs);
  • Outcome-based; and
  • Specific to a clinician's specialty or a given condition.

CMS said MVPs also would allow the agency "to provide more data and feedback to clinicians," which could help clinicians "quickly identify strengths in performance as well as opportunities for continuous improvement in order to deliver the best outcomes possible for patients."

CMS also proposed changes for APMs that participate in MIPs that are intended to streamline reporting requirements. For example, CMS in the fact sheet said it proposed "allowing APM entities and MIPS-eligible clinicians participating in APMs the option to report on MIPS quality measures for the MIPS Quality performance category."

In addition, CMS in the proposed rule requested public comments on how to potentially move its scoring methodology for the Medicare Shared Savings Program more in line with its performance scoring methodology for MIPs. This would allow accountable care organization participants to align their quality efforts across programs, CMS said.

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CMS provides additional changes to help the opioid crisis

CMS under the proposed rule also would expand Medicare coverage for opioid use disorder treatment service. Under the proposed rule, Medicare would pay opioid treatment programs (OTPs) for providing medication-assisted treatment (MAT) to beneficiaries with opioid use disorders. CMS said OTPs would need to be accredited by the Substance Abuse and Mental Health Services Administration in order to qualify for Medicare payments for MAT.

In addition, CMS proposed creating a monthly bundled payment for counseling and management services involving MAT for beneficiaries with opioid use disorders. CMS said the bundled payment "would cover care activities like overall patient management, care coordination, individual and group psychotherapy, and substance-use counseling."

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CMS under the rule also proposed changes related to:

  • Collecting cost, revenue, utilization, and other data on ground ambulance providers;
  • Payments for therapy services that are furnished in whole or in part by physical therapy and occupational therapy assistants;
  • Physician certification statements for ambulance services; and
  • The agency's Open Payments program.

CMS also asked for public comments on how the agency can change its advisory opinion process regarding the so-called "Stark Law" in a way that will reduce provider burdens and uncertainty related to complying with the law. CMS last year had asked for comments about how the physician self-referral law might impede care coordination.

CMS is accepting public comments on the proposed rule until Sept. 27  (Heath, RevCycleIntelligence, 7/29; American College of Cardiology, 7/29; CMS release, 7/29; MPFS proposed rule fact sheet, 7/29; QPP proposed rule fact sheet, 7/29; MFPS/QPP proposed rule, 7/29).

Sept. 3 webconference: Register now for our deep dive into the MPFS proposed rule

CMS just released their 2020 proposed rule on the Medicare Physician Fee Schedule (MPFS), which will ultimately determine Medicare payment rates for the upcoming year.

Join this 30 minute webconference on Tuesday, Sept. 3 at 3 pm ET to hear from Advisory Board experts about the proposed rule—including major changes to office visit reimbursement, care transition management, PA's scope-of-license, and more.

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