Practice Notes

Physician payment in 2020: 5 things to know from the PFS and QPP final rule

by Ken Wallace and Rachel Woods

We read 500 pages of CMS' final rule on the Physician Fee Schedule (PFS) and Quality Payment Program (QPP) so you wouldn't have to. Here's our list of the biggest changes to physician payment in 2020:

Coming soon: How to decode changes to the complex MIPS and APM requirements

1. Primary care specialties benefit from E/M code payment changes starting in 2021

Rather than the consolidated Evaluation and Management (E/M) codes finalized in 2018, CMS chose to adopt the AMA Relative Value Scale Update Committee's (RUC) physician time and work RVU recommendations for E/M visit codes in calendar year (CY) 2021 (Table 35, final rule).

These changes to E/M codes will cause specialties and practices with more established patients—such as endocrinology (+16%), rheumatology (+15%), and family practice (+12%)—to see substantial increases in pay. Conversely, specialties with shorter overall visits or higher procedure volumes will see payment decreases (Table 120). Ophthalmology (-10%), cardiac surgery (-8%), and plastic surgery (-5%) are all expected to experience a decline in payment. That being said, these changes will not go into place until CY 2021, and any changes to the finalized codes, CPT values, or specialties before then could change these specialty-based estimates.

2. New codes reward specialists for high risk care management of a single serious condition

CMS is introducing a new set of codes under Care Management Services this year—Principal Care Management (PCM)—that specialists can leverage as an additional source of reimbursement. Current Chronic Care Management codes require patients to have two or more chronic conditions, an approach that results in a gap in coding and payment for care management of patients with only one chronic condition. Conditions under PCM—expected to last between three and 12 months—are too resource-intensive to treat in a primary care setting and are of sufficient severity to place patient at risk of hospitalization. The expected outcome of PCM is for the patient's condition to be stabilized by the treating clinician so that overall care can be returned to his or her primary care physician (PCP).

Throughout that process, CMS is requiring that the clinician billing for PCM services document ongoing communication in the medical record between all the practitioners furnishing care to the beneficiary. The billing codes for these services—G2064 and G2065, valued at 1.45 wRVUs and 0.61 wRVUs respectively—reflects at least 30 minutes of physician or clinical staff directed towards PCM.

3. CMS continues to prioritize 'patients over paperwork'

The final rule includes two changes which will enable care team members to work closer to top-of-license. For years, physicians, physician assistants (PAs), and advanced practice RNs dealt with redundant policies that made them redocument notes made in the medical record by other caregivers. Under the new rule, these providers may now review and verify instead of redocumenting—removing a barrier to team collaboration and saving providers time. In addition, CMS is changing its supervision requirements for PAs treating Medicare beneficiaries by deferring to state regulations on this issue. This move grants states, payers, and provider organizations greater flexibility to promote collaborative care and allow for more autonomous practice. Both of these changes will take effect on January 1, 2020.

4. MIPS performance expectations continues to rise

The biggest takeaway from the QPP section of the final rule is that pressure to perform well under the Merit-Based Incentive Payment System (MIPS) is intensifying. For CY 2020, CMS is raising the minimum performance threshold to 45 points, with the penalty set at -9%. While the bar is higher than it's ever been, the category weights under MIPS are remaining the same so 2020 will be a good time to refine reporting strategies and maximize scores.

5. CMS finalizes its plan to establish MIPS Value Pathways beginning in 2021

Starting with the 2021 performance period, the new MIPS Value Pathways (MVP) participation framework will seek to overhaul MIPS reporting to reduce burden and make the program more meaningful for participating clinicians and patients. Part of the draw of MVP is that CMS wants to offer a smaller set of measures that are:

  1. Closely aligned with alternative payment models (APMs);

  2. Outcome-based; and

  3. Specific to a clinician's specialty or a given condition.

As CMS has not yet finalized the details of implementation, providers naturally have plenty of questions related to whether participation will be mandatory, what the process will be for selecting measures, and how equity in scoring will be enforced. Though the details of implementation are unclear, one things is certain: CMS intends to solicit more feedback from providers. CMS plans to post opportunities here, so we’d recommend bookmarking this page.

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