2020 Fee Schedule Proposal Outlines E&M Code Changes, Substantial MIPS Changes

July 31, 2019

As previously reported, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule for the 2020 Medicare Physician Fee Schedule (MPFS) and other changes to Medicare Part B and the Quality Payment Program (QPP). ASCO is still analyzing the full proposal, but based on a preliminary analysis, key provisions in the proposed rule are highlighted below:

MPFS

2020 Physician Conversion Factor Remains Flat

The 2020 proposed physician conversion factor is $36.0896. This represents an increase of just five cents from the 2019 conversion factor of $36.0391. While there was no statutorily required update of the conversion factor (the annual update to the physician conversion factor authorized by the Medicare Access and CHIP Reauthorization Act expired in 2019), the agency did apply a relative value unit (RVU) budget neutrality adjustment of 0.14%.

CMS is also implementing a series of standard technical proposals involving practice expense, which include a second year of the market-based supply and equipment pricing update, and standard rate setting refinements to update premium data involving malpractice expense and geographic practice cost indices (GPCIs).

Update to Care Management Services

In recent years, CMS has updated MPFS payment policies to improve payment for care management and care coordination services. CMS estimates that 9% of the Medicare fee-for-service population receives these services annually, yet they believe that gaps remain in coding and payment for such services and are proposing refinements to update these services.

CMS is proposing to increase payment for Transitional Care Management Services (CPT codes 99495 and 99496). These codes describe services provided to Medicare beneficiaries after discharge from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility to the patient’s community setting (home, domiciliary, rest home, or assisted living).

In addition, CMS is proposing a set of Healthcare Common Procedure Coding System (HCPCS) G codes for Chronic Care Management (CCM) Services to replace the CPT codes that currently describe these services. CCM are services that describe providing care coordination and management services to beneficiaries with multiple chronic conditions over a calendar month service period. The new G codes will allow providers to bill incrementally to reflect additional time and resources required in certain cases and differentiate the complexity of illness as measured by time.  In addition, certain billing requirements and elements of the care planning services will be adjusted to reduce the administrative burden with reporting the complex CCM codes.

For patients not meeting the requirements of CCM services, CMS has proposed a new care management service titled Principal Care Management (PCM) for patients with one complex chronic condition and requiring at least 30 minutes of care planning and management. In combination with CCM, PCM allows for reimbursement of oncology care management that is commonly provided by our practices and has been a priority for ASCO’s advocacy efforts.

Finally, CMS is proposing coding and payment policies related to existing and new remote physiologic monitoring services (CPT codes 99457 and 994X0).

Proposed Reduction in Medical Documentation Requirements

In response to feedback received through the Patients Over Paperwork Initiative, CMS is proposing a change in policy to medical documentation requirements. CMS is proposing that physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives could review and verify (sign and date), rather than re-document, notes made in the medical record by other physicians, residents, nurses, students, or other members of the medical team.

Aligning Physician Supervision of Physician Assistants (PA) with State Laws and Scope of Practice Rules

These proposals relate to Medicare responding to the evolving and expanding role of the non-physician provider in various healthcare environments. In response to comments received through a Request for Information (RFI), CMS is proposing to modify their regulation on physician supervision of PAs to give PAs greater flexibility to practice more broadly.

The statutory physician supervision requirement for PA services would be met when a PA furnishes their services in accordance with state law and state scope of practice rules for PAs in the state in which the services are furnished. In the absence of state law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA’s approach to working with physicians in furnishing their services.

Elsewhere in the rule CMS is proposing to defer to state scope of practice requirements on certain services provided by non-physician providers in the ambulatory surgical center (related to anesthetic care) and the hospice environment (related to acceptance of drug orders).

CMS Seeking Comments on Proposed Colorectal Screening Requirements

The Affordable Care Act (ACA) eliminated beneficiary responsibility for coinsurance for recommended colorectal cancer screening tests. Medicare pays 100% of the allowable amount. When colorectal screening services colonoscopies and sigmoidoscopies that begin as a screening service, but where a polyp or other growth is found and removed as part of the procedure, the beneficiary is responsible for co-insurance. Often beneficiaries are surprised when a co-insurance applies when they expected to receive a colorectal screening procedure to which coinsurance does not apply. CMS has said that they do not have the authority to exclude the co-insurance and they have released a wide range of educational material for beneficiaries to explain when the co-insurance would apply.

In this proposed rule, CMS is soliciting comments on whether they should require the physician, or their staff, to provide a verbal notice with a notation in the medical record, or whether they should consider a different approach to informing patients of the copay implications, such as a written notice with standard language that they would require the physician, or their staff, to provide to patients prior to a colorectal cancer screening.

CMS Seeking Comments on Bundled Payments

While historically CMS has made separate payments for each service provided under the MPFS, in recent years CMS has developed bundled payments for the fee schedule and other Medicare payment systems. Many of these models have been implemented under the authority of the Center for Medicare & Medicaid Innovation. CMS is soliciting comments on opportunities to expand the concept of bundling to improve payment for services under the MPFS. While by statute CMS is required to pay for services based on the resources required, they believe there is flexibility within the physician fee schedule to become more efficient.

Proposed Payment Increase for E&M Visits in 2021

In the 2019 MPFS final rule, CMS finalized changes to the coding and payment structure for Evaluation & Management (E&M) services effective calendar year (CY) 2021. In the 2020 proposed rule, CMS is proposing to reverse some of these finalized policies and align E&M coding and payment with changes adopted by the Current Procedural Terminology (CPT) Editorial Panel for E&M services (i.e. eliminating code 99201 and revising code definitions). CMS also proposes to accept a number of payment recommendations made by the American Medical Association’s (AMA) Specialty Society Relative Value Scale (RVS) Update Committee’s (RUC) for office/outpatient visit E&M codes for CY 2021 and the new add-on CPT code for prolonged service time. The AMA RUC-recommended values would increase payment for office/outpatient E&M visits.

HCPCS Code

Current Work RVU

RUC Recommended Work RVU

New Patient Office Visits

99201

0.48

N/A

99202

0.93

0.93

99203

1.42

1.60

99204

2.43

2.60

99205

3.17

3.50

Established Patient Office Visits

99211

0.18

0.18

99212

0.48

0.70

99213

0.97

1.30

99214

1.50

1.92

99215

2.11

2.80

New Prolonged Services Code

99XXX

N/A

0.61

Note: Extracted from table 27B, CY 2020 PFS Proposed Rule (page 510, display copy)

CMS’s revised proposal for E&M services aligns with many of ASCO’s comments submitted in 2018. ASCO appreciates the opportunity to work with AMA and other stakeholders on refining the E&M CPT codes, and we applaud CMS for reviewing provided feedback and proposing to accept the AMA and RUC recommendations.

The Quality Payment Program

Performance Thresholds and Payment Adjustments

The proposed Merit-Based Incentive Payment System (MIPS) performance threshold—or points required to avoid a negative payment adjustment— for CY 2020 is 45 points. This is an increase from 30 points for 2019. Eligible Clinicians (ECs) or practices who fail to participate, when required, or to meet the 45-point threshold may incur up to a negative 9% payment adjustment in 2022.

CMS estimates that MIPS payment adjustments will be approximately equally distributed between negative MIPS payment adjustments ($584 million) and positive MIPS payment adjustments ($584 million) to ECs, as required by the statute to ensure budget neutrality.

Up to an additional $500 million is also available for the 2022 MIPS payment year for additional positive MIPS payment adjustments for exceptional performance for MIPS eligible clinicians whose final score meets or exceeds the proposed additional performance threshold of 80 points. However, the distribution will change based on the final population of MIPS eligible clinicians for the 2022 MIPS payment year and the distribution of final scores under the program. As has been seen in previous years, it is likely that final positive adjustments even for those with exceptional scores will be lower than 9%.

Performance Category Weights

CMS proposes to reduce the weight of the Quality Performance Category and increase the weight of the Cost Performance category. For CY 2020, out of 100 MIPS points available, 40% will be allocated to Quality, 20% to Cost, 25% to Promoting Interoperability (formerly Advancing Care Information) and 15% to Improvement Activities.

New Cost Measures

CMS is proposing 10 new episode-based cost measures including: Acute Kidney Injury Requiring New Inpatient Dialysis, Elective Primary Hip Arthroplasty, Femoral or Inguinal Hernia Repair, Hemodialysis Access Creation, Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation, Lower Gastrointestinal Hemorrhage, Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels, Lumpectomy Partial Mastectomy, Simple Mastectomy, Non-Emergent Coronary Artery Bypass Graft (CABG), and Renal or Ureteral Stone Surgical Treatment.

Advanced Payment Models (APMs)

CMS is proposing refinements to the APM scoring standard to improve flexibility for participants and is proposing a MIPS APM Quality Reporting Credit for APM participants in Other MIPS APMs where quality scoring through the APM is not technically feasible. CMS is proposing to apply the existing extreme and uncontrollable circumstances policies to MIPS eligible clinicians participating in MIPS APMs who are subject to the APM scoring standard and would report on MIPS quality measures.

CMS is also seeking comment on APM scoring in future years of the QPP and on how to potentially align the Medicare Shared Savings Program quality performance scoring methodology more closely with the MIPS Quality Performance scoring methodology.

MIPS Value Pathways

For CY 2021, CMS is proposing “MIPS Value Pathways” (MVPs). The goal is to move away from siloed activities and measures and to move towards an aligned set of measure options more relevant to a clinician’s scope of practice and meaningful to patient care. Clinicians would be scored on a “bundle” of aligned quality and cost measures and improvement activities, with the use of health information technology playing a foundational role.

Other Provisions

CMS Solicits Comments on Stark Advisory Opinion Process

Many stakeholders have urged CMS to update the regulations that governing its advisory opinion process on physician referrals to reduce provider burden and uncertainty around compliance with the Stark Law, which prohibits physicians from referring patients to receive "designated health services" payable by Medicare or Medicaid from entities with which the physician or an immediate family member has a financial relationship. Therefore, CMS is soliciting comment on potential changes to its advisory opinion process in this proposed rule.

CMS Proposes Changes to Open Payments

Under Open Payments, CMS publishes the financial relationships that physicians and teaching hospitals (known as “covered recipients”) have with applicable manufacturers and group purchasing organizations (GPOs). CMS is proposing several changes to Open Payments including: expanding the definition of “covered recipient;” (as required by the SUPPORT Act); modifying payment categories; and 3) standardizing data on reported medical devices.

Visit ASCO in Action for updates on these issues and other cancer policy priorities.