November 13, 2019

A pre-release of the 2020 Medicare Physician Fee Schedule (MPFS) Final Rule has recently become available ahead of its official publication date of November 15.  It will take weeks to fully digest the complete scope and real impact of the 2,475-page Rule, but there are a few components that can be highlighted at this time.  The following paragraphs contain some of the key takeaways arising from the Final Rule that we have gleaned thus far,

Conversion Factor (Non-Anesthesia)

The non-anesthesia conversion factor (CF) for 2020 will remain as proposed in July.  Accordingly, the national CF for next year will be 36.0896, which represents a slight increase from this year’s CF of 36.0391.  Remember that this figure is based on a national average.  The actual CF applicable to your city, metropolitan area or geographical region will vary based on market conditions.

Anesthesia Conversion Factor

In a turnabout for anesthesia providers, the Centers for Medicare and Medicaid Services (CMS) made a surprising change to what it previously recommended in its 2020 MPFS Proposed Rule in terms of the anesthesia conversion factor (ACF).  The agency had proposed an ACF of 22.2774, reflecting a negligible, though technical, increase from this year’s ACF of 22.2730.  However, anesthesia providers will be disappointed to learn that the Final Rule has actually decreased the ACF for next year to 22.2016.

Documentation for Visits in 2021

The Final Rule points to significant changes for evaluation and management (E/M) codes and documentation requirements, beginning in 2021.  The five coding levels for established patients will be retained, but CMS will reduce the number of office/outpatient E/M visits for new patients to four levels.  In addition, code definitions will be revised along with the associated time, per level.  A patient history and exam will only be required “as medically appropriate.”  Finally, clinicians will be allowed to choose the E/M level based on either medical decision-making or the time factor.

Payment for Visits in 2021

The Final Rule addressed the relative value units (RVUs) for E/M services that will take effect in 2021.  As you will recall, RVUs greatly impact overall payment rates.  Based on the RVUs listed in the Final Rule, 2021 payments for E/M services (such as the 99202-99215 code set) will be significantly increased.  For example, payment for CPT 99214 will increase from $109 to $136 per claim in 2021, reflecting a 25 percent increase. Payment for CPT 99213 is scheduled to increase by nearly 30 percent.

Since CMS is committed to budget neutrality where possible, some are concerned that these E/M payment increases will mean payment reductions in other areas.  If the agency significantly increases the payment for the above-referenced E/M code set—which currently represents 20 percent of all Medicare Part B payments—then CMS will quite likely make compensatory cuts in the payment values for other services in 2021.  If such payment rate cuts are forthcoming, it will be more severely felt by those specialties that rarely provide E/M services—unless CMS actually considers that factor when determining RVUs for those specialties.

CRNA Scope of Practice

The Final Rule confirms that nurse anesthetists (CRNAs) are allowed, in keeping with state law, to perform the pre-anesthesia assessment—at least as it concerns the ambulatory surgical center (ASC) setting.  The Rule clarifies that “a physician must examine the patient to evaluate the risk of the procedure to be performed,” while either “a physician or anesthetist must examine the patient to evaluate the risk of anesthesia.”

In other words, in the ASC setting, a physician, such as the surgeon, must perform the preoperative exam and evaluation as to the surgical procedure in question, but a CRNA may perform the pre-anesthesia assessment.  (In the event of a “medically directed” CRNA, the medically directing anesthesiologist must perform the pre-anesthesia assessment.)

PA Supervision

For groups that utilize physician assistants (PAs) in their perioperative, palliative or chronic pain care divisions, you will be interested to know that CMS is clarifying its guidelines relative to physician supervision of a PA.  The Final Rule allows PAs to practice in accordance with the physician supervision laws and scope of practice rules of the state in which their services are rendered.  Where state law is silent on physician supervision of PAs, Medicare requires documentation in the medical record indicating the PA’s “approach to working with physicians” in furnishing his/her services.

According to CMS’s summary of the Rule: “Such physician supervision is evidenced by documenting the PA’s scope of practice and indicating the working relationship(s) the PA has with the supervising physician(s) when furnishing professional services.”

Verifying Student Documentation

New provisions in the Final Rule will ease the burden of billing clinicians when it comes to documenting certain medical records.  According to the actual text of the Final Rule:

We are explicitly naming PA and NP, CNS, CNM and CRNA students as APRN students, along with medical students, as the types of students who may document notes in a patient’s medical record that may be reviewed and verified rather than re-documented by the billing professional.

A summary of the Rule provided by CMS confirms that this change means that physicians, PAs, and advanced practice registered nurses (APRNs), such as nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists, can “review and verify (sign and date),” rather than fully re-document, notes in the medical record that were provided by other members of the medical team, including students.

Opioid Services

The Final Rule provides for new HCPCS codes reflecting telehealth services.  They are as follows: G2086, G2087, G2088.  These codes reflect a bundled episode of care for treatment of opioid use disorders.  The Rule contains several other provisions concerning treatment of opioid abuse.  To view a fuller list of these provisions, you can go to the following link: https://www.cms.gov/newsroom/fact-sheets/finalized-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar.

Quality Payment Program

In a slight change from its proposals as promulgated this past summer, the Final Rule sets forth the following percentage breakdown in Merit-based Incentive Payment System (MIPS) scoring:

• Quality – 45 percent
• Cost – 15 percent
• Promoting Interoperability – 25 percent
• Improvement Activities – 15 percent

The Final Rule sets the performance threshold at 45 percent.  It also raised the exceptional performance threshold to 85 points for 2020, rather than the 80 points previously called for in the Proposed Rule.

Ominously, CMS also finalized more difficult standards for Qualified Clinical Data Registries (QCDRs)—as discussed in the Proposed Rule—including the requirement of greater clinical input on measures.  According to some experts, this change is “expected to drive many QCDRs out of business.”  For a summary and fact sheet on changes to MIPS, you can go to the following CMS link: https://qpp.cms.gov/about/resource-library.

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If we come across additional information in the Final Rule that we believe will prove beneficial to our readers, we will bring that to you in future alerts.  If you have questions on how any of the Rule elements, discussed above, may impact your group or facility, please do not hesitate to contact us at info@MiraMedGS.com.