Highlights

  • The Centers for Medicare & Medicaid Services (CMS) published the Calendar Year (CY) 2020 Proposed 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 the notable changes, CMS is updating several provisions. CMS also is making 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 is also proposing the creation of MIPS Value Pathways (MVPs) beginning with the 2021 performance year.
  • Comments on the proposed rules are due by Sept. 27, 2019. The Final Rule will likely be released in early November, and new Relative Value Units (RVUs) and payment rates will go into effect on Jan. 1, 2020.

The Centers for Medicare & Medicaid Services (CMS) on July 29, 2019, published the Calendar Year (CY) 2020 Proposed 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 the notable changes, CMS is updating several provisions. CMS also is making 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 is also proposing the creation of MIPS Value Pathways (MVPs) beginning with the 2021 performance year.

To learn more about the MPFS notice of proposed rulemaking and the QPP proposals, review the following resources:

Comments on the proposed rules are due by Sept. 27, 2019. The Final Rule will likely be released in early November, and new Relative Value Units (RVUs) and payment rates will go into effect on Jan. 1, 2020.

Below is a summary of highlights of the Proposed Rule.

Physician Fee Schedule Conversion Factor

The proposed 2020 MPFS conversion factor is $36.0896, a slight increase above the 2019 MPFS conversion factor of $36.0391.

Evaluation and Management (E/M) Visits

In the office and outpatient settings, CMS proposes to use the new E/M codes created by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for CY 2021. These new codes will retain five levels of E/M coding for established patient visits and reducing to four levels of E/M coding for new patient visits. The E/M code level would be chosen based on visit duration or medical decision-making and would only require performance of history and exam as medically appropriate. Also, CMS proposes to adopt the AMA Relative Value Scale Update Committee (RUC)-recommended values for office and outpatient E/M codes for the various levels. Therefore, CMS proposes to revise the flat rate of level 2-4 E/Ms that CMS finalized in last year's rule. CMS is specifically seeking input on the following proposed provisions:

  • allow clinicians to determine the E/M visit level based on either medical decision-making or time spent with the patient
  • keep five levels of E/M services for established patients
  • reduce the number of E/M levels to four for office/outpatient E/M visits for new patients
  • revise E/M code definitions to align with the AMA's CPT Editorial Panel's recommendations
  • require performance of history and exam only when a clinician determines that it is medically appropriate
  • adopt all of the AMA's updated RUC recommendations for values of office/outpatient E/M visit codes for CY 2021
  • retain the add-on CPT code for prolonged service time in E/M services, including the ability for this add-on code to be used for primary care and non-procedural specialty services that are part of ongoing management of a patient's chronic condition(s)

Finally, the agency is also proposing to consolidate two Medicare-specific add-on codes for primary care and non-procedural specialty care visits that were finalized in CY 2019 into a single code for implementation in CY 2021

Telehealth Updates

CMS is proposing the addition of three codes to the list of telehealth services: Healthcare Common Procedure Coding System (HCPCS) codes GYYY1, GYYY2 and GYYY3, which describe a bundled episode of care for treatment of opioid use disorder.

  • GYYY1: 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.
  • GYYY2: 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.
  • GYYY3: 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 HCPCS codes GYYY1, GYYY2 and GYYY3 will complement the existing policies related to flexibilities in treating substance use disorders (SUDs) under Medicare telehealth and is welcoming public nominations for additions to the Medicare telehealth list.

Reimbursement for Online Digital Evaluation Services (e-Visits)

CMS is proposing 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 independently bill these services.

CMS also seeks comment on whether a single advance beneficiary consent can be obtained for certain communication-based technology services 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). CMS is considering this change in response to stakeholder feedback that obtaining advance beneficiary consent for each service is overly burdensome and creates a barrier for the use of these services.

Medicare Enrollment of Opioid Treatment Programs (OTPs)

Currently, a gap in Medicare coverage for methadone treatment for opioid use disorder exists, as methadone may only be administered through an opioid treatment program (OTP). These programs, certified by the Substance Abuse and Mental Health Services Administration (SAMHSA), have not previously been an entity eligible to bill Medicare for services. In its 2019 proposed rule, CMS solicited comments on adding OTPs as eligible Medicare providers, and in this rule, proposes definitions and payment rates for Medicare payment of OTPs.

These providers would be able to dispense methadone, as well as buprenorphine and naltrexone, and provide counseling, therapy and toxicology testing. Reimbursement would be at a weekly bundled rate determined annually (though CMS solicits comments on daily or monthly bundled payments instead) and based on the costs of the drugs administered plus the services provided. Therapy and counseling would be allowed either in-person or via audio-video equipment. CMS is proposing 19 new HCPCS codes to describe these services, with payment ranging from $50.23 for a partial week of nondrug treatment to $5,097 for treatment via buprenorphine implant. The copayment for these services would be $0 for a limited trial period.

Review and Verification of Medical Record Documentation

In response to the "Patients Over Paperwork" initiative, CMS is proposing 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 is proposing to establish a general principle to allow the physician, physician assistant (PA) or 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 proposal is intended to apply broadly, CMS proposes to 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 is proposing to increase payment for Transitional Care Management (TCM) and implement a set of Medicare-developed HCPCS G codes for certain Chronic Care Management (CCM) services. Additionally, CMS is proposing to create new coding for Principal Care Management (PCM) services, which would pay clinicians for providing care management for patients with a single serious and high-risk condition.

  • TCM Services: CMS is proposing to revise billing requirements for TCM by allowing TCM codes to be billed concurrently with a list of 14 codes that it finds may complement TCM services rather than substantially overlap or duplicate service.
  • CCM Services: CMS is proposing to adopt two new G codes with new increments of clinical staff time instead of the existing single CPT code (CPT code 99490).
    • The first G code would describe the initial 20 minutes of clinical staff time.
    • The second G code would describe each additional 20 minutes thereafter.
  • PCM Services: CMS is proposing 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.

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 MRI). Requirements were recently summarized in an MLN Matters article.

Medicare Shared Savings Program (MSSP)

CMS is soliciting comment 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. Additionally, CMS is proposing to refine the Shared Savings Program measure set by removing one measure and adding another to the CMS Web Interface, to maintain alignment with proposals under the Quality Payment Program (QPP), and reverting one measure to pay-for-reporting because of a substantive change made by the measure owner.

CMS proposes:

  • to discuss aligning the Shared Savings Program quality measure set with proposed changes to the Web Interface measure set under MIPS per previously finalized policy A change to the claims-based measures
  • to solicit comment on aligning the Shared Savings Program quality score with the MIPS quality performance category score
  • a technical change to correct a cross-reference within a provision of the Shared Savings Program's regulations on the skilled nursing facility (SNF) three-day rule waiver, to conform with amendments to §425.612 that were adopted in the December 2018 final rule

Changes to the Medicare Shared Savings Program (MSSP) Quality Measure Set

To align with the QPP, CMS is proposing to remove one quality measure – ACO-14: Preventive Care and Screening Influenza Immunization – and add one quality measure – ACO-47: Adult Immunization Status – for 23 total measures in Accountable Care Organization (ACO) Performance Year (PY) 2020. Also, CMS seeks comment on how to align the MSSP and MIPS quality performance scoring methodologies to reduce administrative burden and allow ACOs to use resources more efficiently.

Open Payments

CMS is proposing several changes to the "Open Payments" program: 1) expanding the definition of "covered recipient" (as required by the SUPPORT Act); 2) modifying payment categories, and 3) standardizing data on reported medical devices.

Ambulance Services

CMS is proposing to clarify 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. In addition, ambulance suppliers and providers 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 proposing to grant 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 with respect to ground ambulance providers suppliers.

CMS is proposing 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 proposing to reduce 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.

Bundled Payment Comment Solicitation

CMS notes that one of the mechanisms through which it supports innovative payment and service delivery models, for Medicare and other beneficiaries, is through CMS' Center for Medicare and Medicaid Innovation (Innovation Center). As such, CMS is actively exploring the extent to which basic principles of bundled payment, such as establishing per-beneficiary payments for multiple services or condition-specific episodes of care, can be applied within the statutory framework of the Physician Fee Schedule (PFS).

CMS is seeking comment on opportunities to expand the concept of bundling to improve payment for services under the PFS and more broadly align PFS payment with the broader CMS goal of improving accountability and increasing efficiency in paying for the healthcare of Medicare beneficiaries.

RFI on Stark Advisory Opinion Process

CMS is soliciting additional comments on potential changes to its advisory opinion process to address stakeholder comments received from last year's Request for Information (RFI) on how to address unnecessary burden created by the Stark physician self-referral law (Section 1877 of the Social Security Act).

As background, the RFI focused on how it may impede care coordination, and several stakeholders urged CMS to update the regulations governing its advisory opinion process on physician referrals (which is done on a case-by-case basis) to reduce provider burden and uncertainty around compliance with the Stark Law.

RFI on MIPS Value Pathways

CMS is soliciting input on creating MIPS Value Pathways (MVPs) to integrate measures and activities that are meaningful to both specialists and primary care clinicians as well as patients to reduce reporting requirements and streamline MIPS. The MVP framework would begin with the 2021 MIPS Performance Year.

The new MVPs would remove barriers to APM participation and promote value by focusing on quality, interoperability and cost. Additionally, MVPs would create a cohesive and meaningful participation experience for clinicians by moving away from siloed activities and measures and toward an aligned set of measures that are more relevant to a clinician's scope of practice, while further reducing reporting burden and easing the transition to APM

Changes to Merit-Based Incentive Payment System (MIPS)

MIPS Performance Threshold

CMS is proposing to increase the performance threshold to 45 points for the 2020 performance year, up from 30 points in 2019. The performance threshold is the minimum number of points needed to avoid a negative payment adjustment.

MIPS Category Weighting

Quality: CMS proposes reducing MIPS' quality performance category to 40 percent in 2020, 35 percent in 2021 and 30 percent in 2022.

For the performance year 2020, CMS proposes to remove 55 measures, citing minimal uptake, duplication and "topped out" status. It further proposes to add seven new specialty sets that address the eligible clinician groups that were added in CY 2019 final rule, change 78 measures and add four new measures addressing functional status, pain management and immunization status.

CMS is also proposing to establish a guideline for removing quality measures which do not meet the case minimum and reporting volume required for benchmarking after two consecutive years in the MIPS program. For 2020, CMS proposes 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 proposes increasing the weight of MIPS' cost performance category to 20 percent in 2020, 25 percent in 2021 and 30 percent in 2022.

CMS is also proposing to move forward with the inclusion of 10 new episode-based cost measures for implementation in 2020. CMS is proposing changes to both the Medicare Spending Per Beneficiary (MSPB) measure and the Total Per Capita Cost (TPCC) measure. The MSPB measure has a proposed name change from MSPB to MSPB Clinician. CMS has also proposed 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 has proposed numerous 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 is not proposing to change the basic requirements of the IA category. However, CMS has proposed to make 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 is proposing to raise 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 proposes to continue offering high-weighted IA credit for those referring physicians who are early adopters by participating in clinical decision support for 2020.

For 2020 MIPS performance year, CMS is proposing the addition of two new IAs, the modification of seven existing IAs and the removal of 15 activities. CMS has also proposed a set of criteria to be used in determining whether an IA should be removed for future program years. Practices designated as a certified patient-centered medical home (PCMH) will continue to receive an automatic credit for the IAs category, but CMS proposes to modify the definition of a PCMH to be more inclusive. In previous years, CMS listed four accrediting organizations and required that practices receive accreditation from one of those four to be considered a PCMH. CMS proposes to update the PCMH guideline so that it is no longer exclusive to those specific accrediting organizations.

Promoting Interoperability: CMS has included six RFIs related to this component that address the inclusion of opioid measures, ways to improve efficiency, patient exchange information, patient-generated data in electronic health records (EHRs) and engaging in activities that promote safety

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.

The agency said it also is proposing changes to refine MIPS' reporting measures and to establish new requirements for MIPS performance categories that must be supported by health information technology (IT) vendors, QCDRs and qualified registries. CMS also proposed requiring the federal government to publicly report aggregate MIPS data.

New Pathway for MIPS

CMS is proposing 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.

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 condition, and the quality measures and activities for clinicians would be related to the organization. CMS outlines four guiding principles for the MVPs:

  • consist of a limited set of measures that are important to clinicians, reducing burden related to measure selection, scoring and leading to sufficient comparative data
  • include measures that result in comparative performance data that is of value to patients in evaluating clinicians and making care decisions
  • include measures that encourage performance improvements in priority areas
  • reduce barriers to APM participation by using measures that are part of APMs and linking cost and quality measurement

CMS is requesting stakeholder feedback related to the MVPs, including on MVP construction, measure selection, organization, MVP assignment and the transition to MVPs. Also, CMS in the proposed rule requested public comments on how to potentially move its scoring methodology for the Medicare Shared Savings Program (MSSP) more in line with its performance scoring methodology for MIPS. This would allow accountable care organization participants to align their quality efforts across programs, CMS said.

Advanced Alternative Payment Models (AAPMs)

For AAPMs, CMS proposes minor technical changes including for the performance year 2020; an eligible clinician would not be a qualified participant (QP) or Partial QP for the year, if:

  • the APM Entity voluntarily or involuntarily terminates their AAPM contract before the end of the QP performance period, or
  • the APM Entity voluntarily or involuntarily terminates their AAPM contract when the APM Entity would not bear the financial risk