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CMS Finalizes 2020 Physician Fee Schedule Rule

November 14, 2019

Each year, the Centers for Medicare & Medicaid Services (CMS) updates the payment policies, payment rates and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) for the upcoming year. On Nov. 1, CMS published the final 2020 Medicare Physician Fee Schedule Rule for calendar year 2020. The rule incorporates many positive changes that WHA and other commenters suggested. Key provisions of the final rule include:

Evaluation and Management (E/M) Documentation Revisions and Payment Changes. In this final rule, CMS retreated from last year’s controversial rule which would have paid a blended rate for Levels 2 through 4 E/M visits. In 2020, CMS will assign separate payments to all E/M visit levels for new and established patients. This change was strongly supported by WHA. For new patients, there will be four visit levels (Levels 2 through 5). Level 1 is eliminated for new patients; Level 1 visits only describe or include visits performed by clinical staff for established patients. This results in four visit levels for new patients (Levels 2 through 5) and five levels for established patients (Levels 1 through 5). CMS will require histories and exams only when medically necessary. Clinicians will instead use medical decision making or time with the patient to determine the appropriate level of an E/M visit.

CMS is also adopting the American Medical Association’s recommended valuations for all E/M codes, which will increase payment for the codes above the payment amount that would have resulted from a blended payment rate had it gone into effect.

Further, CMS extended to additional types of clinicians the flexibilities finalized in last year’s rule, which permitted physicians, residents and nurses to document a teaching clinician’s presence during the time the teaching clinician participates in services involving residents, rather than requiring the teaching clinician to document this information him or herself. WHA expressed strong support for these changes.

Myocardial PET scan payments. In the final rule, CMS backed away from its proposed significant reductions to the relative value units the code set that describes myocardial PET scans. As stressed by WHA and many other commenters, CMS agreed the proposed pricing would result in significant reductions in payment and said there is substantial work to be done to assure the new valuations for the technical components of these codes accurately reflect the technical inputs. In the interest of maintaining payment stability and protecting patient access to these important services, CMS is delaying the adoption of active pricing for these codes until such time as more accurate sets of inputs can be developed.

Coinsurance for Colorectal Cancer Screening Tests. CMS requested comment on whether it should introduce a notification requirement under which physicians, or their staff, would be required to inform beneficiaries before a colorectal cancer screening that they may incur a coinsurance payment if the physician discovers and removes polyps. WHA strongly recommended that CMS use its existing resources to inform beneficiaries of their possible coinsurance requirement, and that it is inappropriate to require providers to make this notification.

In response, CMS said it intends to undertake a comprehensive review of all their outreach materials, such as the Medicare & You Handbook and Medicare Preventive Services, to see if Medicare policies on payment and coverage for screening colonoscopies can be made clearer.

Payment for Therapy Services. CMS finalized a proposal implementing claims modifiers to identify therapy services furnished in whole or in part by physical therapy and occupational therapy assistants, as required by statute. If 10% or more of services in a therapy visit are furnished by a PT or OT assistant, the visit must be coded with a modifier which indicates that. Once the modifiers attach, the visit would be paid at the 85% of the PT/OT reimbursement rate. The new coding requirements would take effect in the 2020 payment year. Payment cuts would be effective in the 2022 payment year.

In the final rule, responding to comments by WHA and others, CMS revised its proposed policy regarding payment of therapy services furnished concurrently by physical therapists/PT assistants and occupational therapists/OT assistants. In the final rule, the time spent by a PTA/OTA furnishing a therapeutic service “concurrently,” or at the same time, with the therapist will not count for purposes of assessing whether the 10% standard has been met. Only the minutes that the PTA/OTA spends independent of the therapist will count toward the 10% de minimis standard.

Quality Payment Program (MACRA) Changes. In its comments to the proposed rule, WHA supported many of CMS’ changes to the Merit-Based Incentive Payments (MIPS) categories of Quality, Cost/Resource Use, Promoting Interoperability, and Improvement Activity, with the exception of adding 10 new measure to the cost category. WHA was pleased to see that CMS acknowledged, in the final rule, WHA’s and other’s concerns about the cost measures by maintaining the cost category weight at 15% for the 2020 MIPS performance year, rather than increasing it to 20% as initially proposed. WHA urged CMS to maintain the cost category at 15% until clinicians have experience with a correct mix of cost measures, and until more cost measures are endorsed by the National Quality Forum.

MIPS Value Pathways (MVPs). CMS finalized a proposal to create a framework known as MIPS Value Pathways (MVPs) to remove barriers to participation in Alternative Payment Models, move toward alignment of measures relevant to a clinician’s scope of practice, and focus on cost and quality and improvement activities built on population health measures. CMS will develop the MVPs framework in future rulemaking, in consultation with stakeholders. CMS sees implementation beginning in 2021 and suggests that it may be 3-5 years before a transition to the new framework is complete. WHA expressed concern with beginning implementation in 2021. WHA will investigate how CMS will seek stakeholder feedback and report back to our members on this process.

For more detailed information or questions about the final rule, contact WHA Vice President of Policy Development Laura Rose.

This story originally appeared in the November 14, 2019 edition of WHA Newsletter