On November 1, 2019, the Centers for Medicare and Medicaid Services (CMS) released the final calendar year (CY) 2020 Physician Fee Schedule (PFS). The rule includes the annual payment update for physicians in the Medicare program and also includes policies for the Quality Payment Program, care management services, and Opioid Treatment Program (OTPs). Provisions of the final rule generally become effective on January 1, 2020.
CMS Finalizes Additional Changes to Evaluation and Management (E/M) Services for 2021, Payment Increase Expected
CMS is finalizing significant changes to E/M coding as proposed, including reversal of E/M changes previously finalized in 2019. However, E/M changes will not be effective until January 1, 2021 to allow for providers and facilities to prepare for such significant changes. CMS cited general support for these E/M provisions.
Finalized provisions align with E/M coding recommendations by the American Medical Association (AMA). Major updates to E/M coding include determination of E/M visit level based on either time spent with the patient or complexity of medical decision making, retention of 5 levels of E/M visits for established patients, and reduction of the level of E/M coding to 4 levels for outpatient visits. The Agency has also finalized all updated CPT code values and CPT code descriptions, again aligning with AMA recommendations, to reflect a higher payment rate.
CMS also finalized a new CPT code, 99xxx, which describes each 15-minutes of a prolonged E/M office/outpatient visit.
Major Changes to Care Management Finalized, Reflects CMS Initiative to Enable Increased Access
In the CY 2020 proposed rule, CMS proposed to increase payments associated with CPT codes that describe comprehensive care management services (CCM). CMS has finalized all increased payment updates as proposed; this includes all CPT codes for transitional care management (TCM), and advanced care planning (ACP).
CMS finalized their proposal to lift billing restrictions pertaining to chronic care management CPT codes, which was supported by commenters. The Agency feels that these flexibilities will enable greater access to care management services.
CMS Rescinds Proposal of Three G-Codes for Chronic Care Management; Retains One as Proposed
CMS proposed four new HCPCS G-codes to describe additional time spent performing chronic care management (CCM). The agency chose not to finalize CPT codes GCCC1, GCCC3, and GCCC4 due to stakeholder concern about the administrative burden associated with introducing temporary G codes into the CCM coding set until further permanent evaluation by the AMA’s Relative-value scale Update Committee (RUC). However, CMS is finalizing temporary code GCCC2, which reflects non-clinical staff time for CCM; this proposed code will now be referred to as G2058. G2058 may be used a maximum of two times within a service period per beneficiary.
The Agency maintains that existing CPT codes 99487 and 99489 should be used for chronic care management until the AMA has fully reviewed these services.
Care Plan Provisions for CCM Finalized as Proposed
The Agency finalized their proposal to amend care plans for CCM to include the following elements:
- Problem list;
- Expected outcome and prognosis;
- Measurable treatment goals;
- Cognitive and functional assessment;
- Symptom management;
- Planned interventions;
- Medical management;
- Environmental evaluation;
- Caregiver assessment;
- Interaction and coordination with outside resources and practitioners and providers;
- Requirements for periodic review; and
- Revision of the care plan, when applicable.
CMS does recognize that in CCM, patients may require more or fewer services; this list is not mandatory nor exclusive.
CMS Establishes New Principal Care Management (PCM) Category
CMS previously proposed to establish a new CCM category, principal care management (PCM), to account for chronic care management services for the management of only one complex condition. CMS is finalizing this new category, and two new temporary codes, now known as G2065 and G2064, to describe these services. However, CMS is finalizing these two new codes with a higher Relative Value Unit (RVU) than proposed, which will result in a slightly higher payment rate.
No Changes to Payments for Physician-Administered Drugs
The rule did not include any changes to payments for physician-administered drugs.
New Benefit Aims to Expand Access to Opioid Treatment Programs
As part of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act), Medicare beneficiaries will have access to a new benefit for opioid treatment programs (OTPs). The services will include: FDA-approved opioid agonist and antagonist treatment medications; the dispensing and administering of such medications (if applicable); substance use counseling; individual and group therapy; toxicology testing; intake activities; and periodic assessments. Providers will receive a bundled payment containing two components: prescription drugs and non-prescription drug activities.
The payments will be stratified based on clinical needs, including which prescription drug is used to treat the beneficiary. Payment for prescription drugs will be based on 100% of average sales price (ASP); methadone pricing will be based on TRICARE pricing when ASP is not available; oral buprenorphine payment will be based on National Average Drug Acquisition Cost pricing when ASP data are not available. Beneficiaries will not have a copayment for these services.
Bundled Payment for Opioid Use Disorder Finalized
CMS is finalizing a new bundled payment for overall treatment of opioid use disorder (OUD), including management, care coordination, psychotherapy, and counseling activities. Medication assisted treatment (MAT) is not included in the bundle; billing and payment for medications under Medicare Parts B and D remains unchanged and billing for medically necessary toxicology testing would continue to be billed separately under the Clinical Lab Fee Schedule (CLFS). The payment bundle will account for intake activities.
To implement this new bundled payment, CMS is creating two new HCPCS G-codes to describe monthly bundles of service. The codes are limited only to beneficiaries with OUD and there will be add-on codes to account for additional counseling.
CMS Makes Minor Changes to Quality Payment Program, Performance Category Weights to Remain the Same in 2020
In the annual PFS rulemaking, CMS includes policies for the Quality Payment Program (QPP), which includes two tracks: the Merit-based Incentive Payment Program (MIPS) and Advanced Alternative Payment Models. MIPS includes four performance categories: quality, cost, improvement activities, and promoting interoperability. MIPS participants are scored on each of these four categories, which are weighted differently to form a total score. CMS is estimating that just under 880,000 clinicians will be MIPS eligible in the 2020 performance year and that MIPS payment adjustment will be equally distributed between the negative and positive adjustments.
CMS is finalizing a performance threshold of 45 points for the 2020 performance year, up from the previous threshold of 30 points. However, the agency is not finalizing the proposal to set the additional performance threshold at 80 points for the 2020 performance year. The threshold will be set at 85 points instead. The threshold will also remain at 85 points for the 2021 performance year/2023 payment year. Up to $500 million is available in the 2020 performance year/2020 payment year for clinicians whose final score meets or exceeds this additional performance threshold.
CMS is not finalizing their proposal to weigh the cost performance category at 20 percent for the 2020 performance year/2022 payment year. Instead, the cost performance category will continue to be weighted at 15 percent. The quality performance category will remain weighted at 45 percent while the promoting interoperability and improvement activities categories will remain weighted at 25% and 15%, respectively, meaning all four performance categories will be weighted the same in the upcoming 2020 performance year as they were in 2019. CMS has indicated they will revisit the weights of the cost and quality categories in future rulemaking.
In addition, ten new episode-based measures will be added to the cost performance category and process measures were removed from the quality performance category. Two new improvement activities were added, including a new Drug Cost Transparency improvement activity.
Participants in the Advanced Alternative Payment Models track are eligible for an incentive payment. CMS is estimating that the total lump sum APM Incentive Payment will be between $535 and $685 million for the 2020 performance year/2022 payment year.
MIPS Value Pathways Coming in 2021 Performance Year
In the proposed PFS rule, CMS put forth creation of the MIPS Value Pathways (MVPs) beginning with the 2021 performance year/2023 payment year. The agency believes this pathway will decrease clinician burden and improve the quality of performance data. CMS has not yet indicated whether participation in an MVP will be mandatory or optional. The agency indicated they plan to move forward with this idea in future policy making for the QPP, with a gradual transition beginning in the 2021 performance year. CMS will likely provide more details on the MVPs in future rulemaking. In this rule, CMS merely establishes a definition for MVPs as “a subset of measures and activities established through rulemaking.”
CMS Defers to State Supervision Requirements for Physician Assistants
Medicare has traditionally required that physician assistants (PAs) practice under the general supervision of a physician which is a more stringent requirement than the one applied to Nurse Practitioners (NPs) who only have to have a collaboration agreement with a physician. This rule changes the PA supervision requirement to one more consistent with the Medicare requirement for NPs. Medicare defaults to the state requirement for supervision, in the absence of a state standard Medicare imposes a collaboration standard. The requirement that PA services be billed by their employer is statutory and therefore does not change.
New Practitioners Added to Open Payments Program Covered Recipients
CMS has finalized the proposal to add physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), certified registered nurse anesthetists (CRNAs), and certified nurse midwives (CNMs) to the list of practitioners that will be covered by the open payment regulations. This was done to comply with the SUPPORT Act.
CMS Expands Access to Intensive Cardiac Rehabilitation
Patients with stable chronic heart failure (EF<=35% NYHA II-VI) have been added to the list of covered conditions for intensive cardiac rehabilitation (ICR). CMS also established that the national coverage decision (NCD) process would be used to add additional indications if they were proposed.
New Face-to-Face Requirement for Telehealth Services Finalized
CMS finalized the proposal to add face-to-face requirements for three new HCPCS G codes describing new bundled treatment of opioid use disorders. G2086 through G2088 delineate office-based treatment planning and therapy based the time length and month of treatment.