• The Centers for Medicare & Medicaid Services (CMS) on Nov. 1, 2019, published the Calendar Year (CY) 2020 Final Rule for the Medicare Physician Fee Schedule (MPFS). The MPFS dictates Medicare rates and policies under Part B, while the Quality Payment Program (QPP) implements two key value-based payment programs: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).
  • CMS is finalizing significant changes to evaluation and management (E/M) and chronic care management services, citing greater flexibility and increased accuracy in codifying services. This year's MPFS also includes new requirements for certain telehealth services and coverage for additional opioid treatment services. CMS also finalized the creation of MIPS Value Pathways (MVPs) beginning with the 2021 performance year/2023 payment year.
  • The Final Rule, along with the new Relative Value Units (RVUs) and payment rates, will go into effect on Jan. 1, 2020.

The Centers for Medicare & Medicaid Services (CMS) on Nov. 1, 2019, published the Calendar Year (CY) 2020 Final Rule for the Medicare Physician Fee Schedule (MPFS). The MPFS dictates Medicare rates and policies under Part B, while the Quality Payment Program (QPP) implements two key value-based payment programs: the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs).

Among notable changes, CMS is finalizing significant changes to evaluation and management (E/M) and chronic care management services, citing greater flexibility and increased accuracy in codifying services. Additional updates in this year's MPFS include new requirements for certain telehealth services and coverage for additional opioid treatment services. CMS also finalized the creation of MIPS Value Pathways (MVPs) beginning with the 2021 performance year/2023 payment year.CMS has not yet indicated whether participation in an MVP will be mandatory or optional.

To learn more about the MPFS and QPP Final Rule, review the following resources:

The Final Rule, along with the new Relative Value Units (RVUs) and payment rates, will go into effect on Jan. 1, 2020.

Below is a summary of highlights of the Final Rule.

Physician Fee Schedule Conversion Factor

CMS finalized a CY 2020 conversion factor of $36.0896, a slight increase above the 2019 MPFS conversion factor of $36.0391. Because the annual update to the physician conversion factor authorized by the Medicare Access and CHIP Reauthorization Act (MACRA) expired in 2019, there was no statutorily required update of this conversion factor. However, the new rate reflects a budget neutrality adjustment based on changes to RVUs.

Evaluation and Management (E/M) Visits

CMS finalized its revised approach to billing for evaluation and management (E/M) visit codes. The changes will take effect on Jan. 1, 2021, to allow time for provider education, changes to workflow, and updates to EHRs and systems.

The final rule:

  • retained five levels of coding for established patients
  • set four levels for office and outpatient E/M visits for new patients
  • revised the times and medical decision-making process for all office-based E/M codes and requires performance of history and exam only as medically appropriate
  • finalized a new Current Procedural Terminology (CPT) code, 99xxx, which describes each 15 minutes of a prolonged E/M office/outpatient visit

CMS, however, is not making any changes to the E/M office visits captured in the 10-day and 90-day global codes. CMS plans to continue to assess and develop an approach to revaluing global surgery procedures, including the associated post-operative visits.

These finalized provisions align with the adoption by CMS of the American Medical Association (AMA) Specialty Society Relative Value Scale Update Committee's (RUC) recommended work RVUs for all of the office/outpatient E/M visit codes and the new prolonged services add-on code. The payment rates were set after the committee surveyed more than 50 specialty types to find the average time they spent with patients for each billing level. The RUC-recommended values yield higher work RVUs for most office/outpatient E/M services. The AMA RUC background, recommendations and the RUC votes on E/M are posted on the AMA website.

Notably, by law, CMS is required to make an annual adjustment to physician payments to maintain budget neutrality if the changes to the work RVUs result in an increase or decrease in the overall fee schedule outlays. Thus, increases in reimbursement for E/M services will result in a positive impact for providers that receive a large part of their revenue from E/M, i.e., family medicine. Whereas for other providers that do not frequently bill E/M codes, CMS is expecting a negative impact.

Given that the revised codes and values do not take effect until CY 2021, CMS has not estimated the specific impact across the code set; however, it did publish illustrative implications in the proposed rule (Table 120). CMS did not update the estimates from Table 120 in the final rule because there are unknowns regarding other changes that will occur in CY 2021. CMS will provide a specific impact in next year's rulemaking. Those adversely impacted may elect to work with Congress to implement positive updates to the conversion factor (CF) to help offset potential losses.

Telehealth Updates

CMS finalized the proposal to add face-to-face requirements for three new Healthcare Common Procedure Coding System (HCPCS) G codes describing the new bundled treatment of opioid use disorders. Codes G2086 through G2088 delineate office-based treatment planning and therapy based on the time length and month of treatment.

  • G2086: Office-based treatment for opioid use disorder, including the development of the treatment plan, care coordination, individual therapy, and group therapy and counseling; at least 70 minutes in the first calendar month.
  • G2087: Office-based treatment for opioid use disorder, including care coordination, individual therapy, and group therapy and counseling; at least 60 minutes in a subsequent calendar month.
  • G2088: Office-based treatment for opioid use disorder, including care coordination, individual therapy, and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (list separately in addition to code for primary procedure).

CMS believes that adding these HCPCS codes will complement the existing policies related to flexibilities in treating substance use disorders (SUDs) under Medicare telehealth. Specifically, Section 2001(a) of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act removes the geographic limitations for telehealth services furnished on or after July 1, 2019, for individuals diagnosed with an SUD for the purpose of treating the SUD or a co-occurring mental health disorder.

Reimbursement for Online Digital Evaluation Services (e-Visits)

CMS finalized its policy to create six new non-face-to-face codes to describe and reimburse for "patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office." The code descriptors refer to "online digital evaluation and management service, for an established patient, for up to seven days, a cumulative time during the seven days" and are reimbursed in increments of 5-10 minutes, 11-20 minutes, and 21 or more minutes. Three of the codes can be reported by practitioners who can independently bill E/M services, while the other three will apply to non-physician healthcare professionals who cannot separately bill these services.

CMS also sought comment on whether a single advance beneficiary consent can be obtained for certain communication-based technology services (CTBS) designated in the final 2019 MPFS, including virtual visits (HCPCS 2012), remote evaluation of images (HCPCS 2010), and Interprofessional Internet Consultations (CPT codes 99446-99449, 99451 and 99452 ). Based on commenter support, CMS is finalizing a policy to permit a single consent to be obtained for multiple CTBS or interprofessional consultation services. Based on feedback from commenters, CMS believes an appropriate interval for the single consent is one year and is finalizing that the single consent must be obtained at least annually.

Medicare Benefit for Opioid Treatment Programs

As part of the SUPPORT for Patients and Communities Act, Medicare beneficiaries will have access to a new benefit for opioid treatment programs (OTPs). The services will include U.S. Food and Drug Administration (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 percent of the average sales price (ASP); methadone pricing will be based on TRICARE pricing when ASP is not available; and oral buprenorphine payment will be based on National Average Drug Acquisition Cost pricing when ASP data is not available. Beneficiaries will not have a copayment for these services.

Bundled Payment for Opioid Use Disorder

CMS is finalizing a new bundled payment for the 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.

Review and Verification of Medical Record Documentation

In response to the "Patients Over Paperwork" initiative, CMS finalized broad modifications to the documentation policy so that certain providers could review and verify (sign and date), rather than redocumenting, notes made in the medical record by other physicians, residents, nurses, students or other members of the medical team.

CMS established a general principle to allow the physician, the physician assistant (PA) or the Advanced Practice Registered Nurse (APRN) who furnishes and bills for their professional services to review and verify, rather than redocument, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. This principle would be applied across the spectrum of all Medicare-covered services paid under the MPFS.

Because this is intended to apply broadly, CMS will amend regulations for teaching physicians, physicians, PAs and APRNs to add this new flexibility for medical record documentation requirements for professional services furnished by physicians, PAs and APRNs in all settings.

Care Management Services

CMS finalized its policy to increase payment for Transitional Care Management (TCM). CMS revised billing requirements for TCM by allowing TCM codes to be billed concurrently with a list of 14 codes (Table 20) it finds may complement TCM services rather than substantially overlap or duplicate services.

Additionally, CMS finalized its policy to create new coding (G2064 and G2065) for Principal Care Management (PCM) services, which would pay clinicians for providing care management for patients with a single serious and high-risk condition. CMS is finalizing these two new codes with a higher RVU than proposed, which will result in a slightly higher payment rate. CMS established that PCM services include coordination of medical and/or psychosocial care related to the single complex chronic condition, provided by a physician or clinical staff under the direction of a physician or other qualified healthcare professional.

Finally, CMS created a new code for additional time spent beyond the initial 20 minutes allowed in the current coding for chronic care management (CCM) services (G2058) and established a policy to allow for a single consent per year for communication technology-based services rather than requiring the provider to obtain consent with each interaction.

Appropriate Use Criteria (AUC)/Clinical Decision Support (CDS)

CMS is proposing no changes regarding implementation of the mandate requiring that clinicians consult appropriate use criteria (AUC) through a qualified clinical decision support mechanism (CDSM) starting Jan. 1, 2020, when ordering advanced imaging services (i.e., SPECT/PET MPI, CT and MR). Requirements were recently summarized in an MLN Matters article.

Medicare Shared Savings Program (MSSP)

In the proposed rule, CMS sought public comments on how to potentially align the Medicare Shared Savings Program (MSSP) quality performance scoring methodology more closely with the Merit-Based Incentive Payment System (MIPS) quality performance scoring methodology. In the final rule, CMS notes that it will continue to explore updates and changes to facilitate such alignment.

Comment Solicitation on Opportunities for Bundled Payments Under the MPFS

In the proposed rule, CMS sought public comments on opportunities to expand the concept of bundling to recognize efficiencies among physicians' services paid under the MPFS and better align Medicare payment policies. The final rule indicated that many comments were received in response to this request, and that CMS will consider them for future rulemaking on this topic.

Open Payments

The Open Payments program is a statutorily mandated program that promotes transparency by providing information to the public about the financial relationships between the pharmaceutical and medical device industry, and certain types of healthcare providers. CMS finalized several changes to the "Open Payments" program: 1) expanding the definition of "covered recipient" (as required by the SUPPORT for Patients and Communities Act), 2) modifying payment categories and 3) standardizing data on reported medical devices.

Ambulance Services

CMS clarified that there is no CMS-prescribed form for physician certification statements (PCSs) for ambulance transports. So long as the elements required by regulation are clearly conveyed, ambulance suppliers and providers would be free to choose the format by which the information is displayed, and they may find that other forms that may be required by other legal requirements to perform the transport may also satisfy the function of the PCS.

CMS is also granting ambulance suppliers and providers greater flexibility around who may sign a non-physician certification statement in certain circumstances. The proposal would also add licensed practical nurses (LPNs), social workers and case managers as staff members who may sign the non-physician certification statement if the provider/supplier is unable to obtain the attending physician's signature within 48 hours of the transport.

Ground Ambulance Data Collection System

The Bipartisan Budget Act (BBA) of 2018 requires the Secretary of Health and Human Services to develop a data collection system to collect cost, revenue, utilization and other information determined appropriate to ground ambulance providers and suppliers.

CMS finalized the data collection format and elements, a sampling methodology that CMS would use to identify ground ambulance organizations for reporting each year through 2024 and not less than every three years after 2024, and reporting timeframes. CMS is also reducing by 10 percent the payments that would otherwise be made to a ground ambulance organization that is identified for reporting but fails to sufficiently submit data, as well as a process under which a ground ambulance organization can request a hardship exemption that, if granted by CMS, would allow it to avoid the payment reduction.

Changes to Merit-Based Incentive Payment System (MIPS)

MIPS Performance Threshold and Incentives

CMS finalized its proposal to increase the performance threshold to 45 points for the 2020 performance year/2022 payment year, up from 30 points in 2019. CMS intends to increase the threshold to 60 points in the 2021 MPFS performance year. The performance threshold is the minimum number of points needed to avoid a negative payment adjustment.

CMS also finalized an additional increase for exceptional performance to 85 points (up from 80 in the proposed rule) in 2020.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/2022 payment year for clinicians whose final score meets or exceeds this additional performance threshold.

Finally, CMS will also move forward with increasing the minimum MIPS penalties and maximum MIPS base incentives from -7 percent/+7 percent in 2019 to -9 percent/+9 percent for 2020.

MIPS Category Weighting

Quality: CMS will maintain the quality performance category at 45 percent for 2020 performance year (no change from 2019). CMS has outlined its plan to lower the weight to 35 percent in 2021 and finally 30 percent in 2022.

CMS also established a guideline for removing quality measures that do not meet the case minimum and reporting volume required for benchmarking after two consecutive years in the MIPS program.

For 2020, CMS finalized its policy to continue allowing eligible clinicians and groups to submit a single measure via multiple collection types (e.g., MIPS Clinical Quality Measures (CQM), Electronic Clinical Quality Measures (eCQM), Qualified Clinical Data Registry (QCDR) measures and Medicare Part B claims measures).

Cost: CMS will maintain the MIPS' cost performance category at 15 percent (same as 2019). However, CMS said it "will revisit increasing the weight of the cost performance category in next year's rulemaking to ensure clinicians are prepared for the significant increase in category weight by the 2024 MIPS payment year."

CMS will also move forward with the inclusion of 10 new episode-based cost measures for implementation in 2020:

  1. Acute Kidney Injury Requiring New Inpatient Dialysis
  2. Elective Primary Hip Arthroplasty
  3. Femoral or Inguinal Hernia Repair
  4. Hemodialysis Access Creation
  5. Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
  6. Lower Gastrointestinal Hemorrhage
  7. Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
  8. Lumpectomy Partial Mastectomy, Simple Mastectomy
  9. Non-Emergent Coronary Artery Bypass Graft (CABG)
  10. Renal or Ureteral Stone Surgical Treatment

CMS also finalized changes to both the Medicare Spending Per Beneficiary (MSPB) measure and the Total Per Capita Cost (TPCC) measure. CMS will advance a service exclusion list that is considered clinically unrelated to the index admission of the revised MSPB clinician measure, and a change in the attribution methodology to distinguish between medical episodes and surgical episodes. CMS will advance changes to the TPCC measure, which include a revised primary care attribution methodology, a revised risk adjustment methodology, service and specialty category exclusions for clinicians that perform non-primary care services, and evaluating beneficiary cost every month rather than an annual basis.

Improvement Activities (IA): CMS will maintain the performance category at 15 percent (no change from 2019).

CMS also finalized significant changes to IA reporting requirements for group reporters. Previously, groups could report an IA as long as one member of the practice had completed that IA. For 2020, CMS raised that requirement to at least 50 percent of the group within the same continuous 90-day period.

Recognizing the importance of appropriate use criteria (AUC) for diagnostic imaging, CMS will continue offering high-weighted IA credit for those referring physicians who are early adopters by participating in clinical decision support for 2020.

For the 2020 MIPS performance year, CMS finalized the addition of two new IAs, including a new Drug Cost Transparency IA. CMS is also modifying seven existing IAs and removing 15 activities. CMS has also finalized a set of criteria to be used in determining whether an IA should be removed for future program years.

Promoting Interoperability: CMS will maintain the performance category at 25 percent (no change from 2019).

CMS finalized its proposal that the required percentage of hospital-based MIPS eligible clinicians billing under groups or virtual groups be reduced from 100 percent to 75 percent to qualify for that special status as a group or virtual group. This change would begin with the 2022 MIPS payment year.

Facility-Based Scoring: A facility-based group would be defined as one in which 75 percent or more of the MIPS eligible clinicians national provider identifiers (NPIs) billing under the group's taxpayer identification number (TIN) are eligible for facility-based measurement as individuals. There are no submission requirements for individual clinicians in facility-based measurement, but a group must submit data in the Improvement Activities or Promoting Interoperability performance categories to be measured as a group under facility-based measurement. CMS will automatically apply facility-based measurement to MIPS eligible clinicians and groups who are eligible for facility-based measurement and who would benefit by having a higher combined Quality and Cost score. There are no proposed changes for facility-based scoring eligibility.

Qualified Clinical Data Registry (QCDR)

CMS made updates to requirements for QCDR measures and the services that third-party intermediaries must provide (beginning with the 2021 performance period).

New Pathway for MIPS

CMS finalized its policy to create the MIPS Value Pathways (MVPs) beginning with the 2021 performance year/2023 payment year. The agency believes that this pathway will decrease clinician burden and improve the quality of performance data. Ultimately, CMS wants to use this framework so that all MIPS eligible clinicians will have to participate through an MVP or a MIPS APM. Notably, CMS has not yet indicated whether participation in an MVP will be mandatory or optional.

An MVP would connect measures and activities across three categories in MIPS: quality, cost and improvement activities. Initially, a uniform set of Promoting Interoperability measures would be included in all MVPs. These pathways would be organized around specialty or health conditions, and the quality measures and activities for clinicians would be related to the organization.

Advanced Alternative Payment Models (AAPMs)

For AAPMs, CMS finalized minor technical changes, including for the performance year 2020, including adding a category of Aligned Other Payer Medical Home Models as well as modifying the definitions of marginal risk and expected expenditures for Other Payer Advanced APMs.

CMS is not finalizing its proposal to apply partial qualifying APM participant (QP) status only to the TIN/NIP combination(s) through which an individual eligible clinician attains partial QP status.