The Centers for Medicare and Medicaid Services (CMS) recently published a final rule draft of Medicare Physician Fee Schedule (MPFS) before its official publication date i.e November 15. Rule book having 2,457 pages will take us weeks to fully digest the complete scope and actual impact on clinicians, but at the heart of the MPFS is the annual conversion factor update. The proposed 2020 MPFS conversion factor will be $36.09, i.e. +0.14 % than the 2019 conversion factor which was $36.04.
Below are the finalized proposals of key interest to health plans and payers that will pass into effect as of January 1, 2020.
1. Documentation for Visits in 2021 – E/M Office Visit Services
- E/M office visit services CMS proposed changes for evaluation and management codes and documentation requirements, beginning in 2021. The CPT coding will have five coding levels for established patients. CMS will cut back the number of office/outpatient visits for new patients to four levels and revise the code definitions along with the associated time, and medical decision-making process per level.
- History and physical examinations should continue to be performed as medically appropriate; Finally, clinicians will be allowed to choose the E/M level based on either medical decision-making or the time factor.
- CMS proposes to implement a Medicare-specific add-on code for office/outpatient visits, identifying the complexity connected with visits that serve as a focal point for ongoing care related to a patient’s single, serious, or complex chronic condition.
- CMS impact tables indicate that more than $1.5 billion will be redistributed between specialties if this code is implemented.
- The policy changes for the E/M office visits would be effective for services starting January 1, 2021.
2. Care Management Services
In addition to changes in office/outpatient E/M visits, CMS finalized several changes to care coordination and management codes.
Transitional Care Management (TCM): Care management service provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays.
- Patients who receive TCM services have lower hospital readmission rates, lower mortality, and incur lower costs. Therefor CMS is increasing payment for care management in TCM services. CMS also proposes to increase payment for the two Transitional Care Management (TCM) codes as recommended by the RUC.
Chronic Care Management (CCM): CCM services are those within a calendar month provided to beneficiaries with multiple chronic conditions.
- CMS is proposing to adopt a new Medicare-specific code for CCM which will permit providers to bill incrementally to reflect the additional time spent beyond the initial 20 minutes allowed in the current coding.
- CMS proposes to clarify the language describing the comprehensive care plan required for CCM codes.
- CMS requests comment on whether to implement G codes for these expanded CCM codes for 2020 or wait for anticipated changes to CPT in 2021.
Principal Care Management (PCM): PCM service would pay clinicians for providing care management for patients with single serious and high-risk conditions
- CMS proposes to create two new codes for PCM services, which would pay physicians for providing care management to patients with a single serious and high-risk condition.
- The current CCM codes require patients to have two or more chronic conditions. As part of its rationale, CMS cites proposals submitted to the Physician-focused Payment Model Technical Advisory Committee for managing patients with one serious chronic condition. CMS estimates an additional $125 million in annual spending for these services, offset by reductions to the Medicare conversion factor.
3. Remote Patient Monitoring (RPM)
- CMS will implement a new CPT code to report time spent above and beyond the initial 20 minutes for evaluating, reviewing and taking action based on health data reported through RPM, including interactive communication with the patient or caregiver.
- CMS previously has required the billing practitioner to provide direct supervision (i.e., in-person) for clinical staff furnishing RPM services. Effective January 1, CMS will permit these services to be performed under general supervision.
- For all RPM services, CMS proposes to change, previously required direct supervision to now general supervision. This allows clinical staff to monitor the patient’s health data and interact with them remotely.
- CMS has created an RPM add-on code, CPT 99458, similar to the non-complex CCM add-on code. This will help to describe and reimburse for patient-initiated digital communications that require a clinical decision.
4. Opioid Treatment Programs (OTPs): Medicare Coverage For Opioid Use Disorder (OUD)
CMS sought comments (based on a concept paper jointly developed by the AMA and American Society of Addiction Medicine) on designing a new bundled payment for office-based management of patients with OUD known as an Alternative Payment Model (APM).
- In the current rule, CMS proposes new codes that would provide a monthly payment for a bundled episode of care, including the development of a treatment plan, care coordination, individual and group therapy, and counseling for patients with OUD.
- The bundled payments would exclude medications approved by the FDA for use in the treatment of OUD.
- There would be separate payments for the first month of treatment to cover induction and development of the treatment plan, payments for subsequent months of treatment (with no limit on the duration of treatment), and an add-on code to cover patient circumstances that require substantial extra resources to manage.
- The bundled payment rate is based on a drug and non-drug component and is stratified into several codes to account for differences in beneficiaries’ clinical needs.
- CMS has also finalized an increased payment rate for the non-drug component of the bundled payment rate and add-on codes for intake activities, periodic assessments and take-home doses of drugs.
- CMS is finalizing a policy to allow counseling and therapy services described in the bundled payments, to be furnished via two-way interactive audio-video communication technology as clinically appropriate.
- CMS is also finalizing that there will be zero beneficiary co-payment for 2020. OTP providers must enroll in Medicare to receive Medicare payment for these services. Click here for more onhow to enroll in Medicare Information.
5. Quality Payment Program (QPP) changes
The new Medicare physician fee schedule rule also includes updates to the Quality Payment Program, the incentive payment program enacted in 2015 with the passage of the Medicare Access and CHIP Reauthorization Act, or MACRA, to replace the sustainable growth rate method of determining updates to the fee schedule.
The QPP includes two tracks:
- The Merit-based Incentive Payment System (MIPS)
- The Advanced Alternative Payment Model (AAPM).
Unlike past years, the agency is maintaining the scoring methodology for the QPP and did not make significant changes to the AAPM track.
Changes Made In Merit-based Incentive Payment System (MIPS)
Some changes to other parts of the MIPS track for the performance year 2020, which corresponds to the payment year 2022.
The MIPS performance category weightings (45% quality, 25% promoting interoperability, 15% cost, and 15% improvement activities) will not change this year, nor will the performance periods (12 months of data for quality and cost and 90 days for improvement activities and promoting interoperability).
The MIPS performance threshold has increased from 30 points to 45 points. The exceptional performance threshold will increase from 75 points to 85 points.
- Those who score above or below the performance threshold will receive Medicare Part B payment adjustments on a sliding scale up to +/-9%.
- Those who score above the exceptional performance threshold will be eligible for an additional payment adjustment of up to 10%, paid on a sliding scale.
For more information
These updates reflect a high-level list of the most important changes you may want to know as 2020 begins. For more information, check your 2020 CPT and HCPCS books, the CMS fact sheet on the physician fee schedule, and the CMS QPP Resource Library.