August 7, 2019

In late July, the Centers for Medicare and Medicaid Services (CMS) released a preview of its proposed changes to the Medicare Physician Fee Schedule (MPFS) for 2020.  The release also contained proposals that would affect the Quality Payment Program (QPP) for next year.  Together, these suggested revisions to the current fee schedule and QPP constitute 1,704 pages of legal language that will take some time to review and clarify.  Nevertheless, we felt it important to provide you with our initial assessment of the “proposed rule,” along with some of the highlights gleaned thus far.  Here, then, is our first take on what’s in store for 2020:

Conversion Factor

The item that may be of greatest interest to physicians and other billing practitioners is the extent to which the conversion factor (CF) will be adjusted in 2020.  You will recall that this factor, determined by the Resource Based Relative Value System (RBRVS), reflects the amount paid per relative value unit (RVU) under the fee schedule.  The proposed rule does indeed include an adjustment over this year’s CF; however, the non-anesthesia CF is proposed to increase by only five cents—from $36.04 to $36.09 in rounded-off numbers.

The rule essentially recommended no change in the anesthesia CF for next year, opting to keep it at the current rounded rate of $22.27.

Impact of RVU Revisions

Regardless of the near negligible increase in the 2020 CF, practices may experience varying degrees of financial impact based on CMS’ tweaking of various RVU components within each specialty code set.  Change in actual reimbursement will ultimately be based upon a range of proposed revisions to the physician work, practice expense and malpractice RVUs related to multiple codes.  A summary of these revisions can be found in Table 110 of the proposed rule.

According to an analysis of RVU revisions, as found in the proposed rule, changes in overall payment rates are expected to range from a decrease of four percent for ophthalmology, for example, to an increase of three percent for clinical psychologists and clinical social workers. According to the American Society of Anesthesiologists (ASA), the payment impact for anesthesiology is expected to be negligible, while chronic pain providers may see an overall payment increase of one percent.

More Changes for E/M

As you may recall, CMS had previously proposed significant changes to the way in which certain evaluation and management (E/M) services were to be documented and paid.  However, those proposals were either altered or delayed in the 2019 final rule.  With the proposed 2020 rule, CMS is once again moving the goal posts by proposing new revisions to the E/M documentation and payment policies, which include the following:

• Adopt revisions in E/M code descriptors, beginning January 1, 2021.  The AMA’s CPT Editorial Panel developed these new descriptors in an attempt to better capture the intention and requirement of each code.
• Table the previous plan to base payment on a blended rate for E/M levels two through four (2-4).  Instead, CMS proposes to retain a separate payment amount for each individual level of service.
• Revise work and practice expense RVU calculations based on recommendations by the AMA Relative Value Scale Update Committee.  Generally, E/M visits will provide increased reimbursement based on this re-weighting of RVUs, beginning in 2021.
• Retain five levels of coding for established patients, but reduce the number of levels to four for office/outpatient E/M visits for new patients.
• Revise the time component associated with each E/M code.
• Revise the medical decision-making process for all E/M codes.
• Require performance of history and exam only where medically appropriate.
• Allow clinicians to choose the visit level based on either (a) medical decision making, or (b) time.

CDSM Requirement

The proposed rule keeps the requirement that, beginning January 1, 2020, clinicians must consult appropriate use criteria through a qualified clinical decision support mechanism (CDSM) when ordering advanced imaging services (i.e., SPECT/PET MPI, CT and MR).

New Specialty Codes

Among the many new proposals set forth in the July rule is the creation of a new set of “G codes” for certain chronic care management services, as well as a new code set for “principal care management” services.  This latter set of codes concerns the provision of care management on behalf of patients who present with a “single serious and high risk condition.”

Supervision of PAs

The rule proposes to modify the supervision requirements relative to physician assistants (PAs). According to CMS, Medicare’s requirement that physicians provide supervision of PA services “would be evidenced by documentation in the medical record of the PA’s approach to working with physicians in furnishing their services,” where state law allows.

Hospital Outpatient Rule

In addition to the proposed Physician Fee Schedule, CMS also released the proposed 2020 Hospital Outpatient Prospective Payment System (OPPS) rule.  This rule includes a 2.7 percent payment increase for hospitals.

Quality Payment Program

The Quality Payment Program (QPP) was enacted by Congress under MACRA and contains two major sub-programs that seek to measure quality and cost: Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).  With that background in mind, here are some of the suggested program revisions for 2020, as found in the proposed rule:

• Increase in the performance threshold (the minimum number of points an eligible clinician must attain to avoid a negative payment adjustment) from 30 points in 2019 to 45 points in 2020 and 60 points in 2021.
• Exceptional performance threshold to be increased to 80 points in 2020 and 85 points in 2021.
• Weight of the Quality performance category to be lowered to 40 percent in performance year 2020, 35 percent in 2021 and 30 percent in 2022.
• Weight increases proposed in the Cost performance category: 20 percent in the 2020 performance year, 25 percent in 2021, and 30 percent in 2022.
• Increase in the data completeness threshold to be submitted by ECs.
• Increase in the threshold for group reporting relative to the Improvement Activity performance category.
• Revised requirements for Qualified Clinical Data Registry (QCDR) measures, including services third-party intermediaries must provide, beginning in 2021.
• Implementation of a new MIPS Value Pathways (MVPs) reporting option, beginning with the 2021 MIPS performance year.  Those ECs opting to participate via the MVPs framework would report a smaller set of measures that are specialty-specific, outcome-based, and more closely aligned to APMs.
• The low-volume threshold, EC types, MIPS performance periods, CEHRT requirements, and small practice bonus levels remain unchanged in the proposed rule.

The proposed MPFS for 2020 will officially be published in the Federal Register later this month.  Comments on the proposed rule should be submitted to CMS by September 27, 2019.  Legal and compliance specialists at MiraMed Global Services will continue to analyze the proposed MPFS and provide updates to our client-partners in the weeks ahead or as warranted.