CMS 2020 Proposals Clarify Changes to E&M Codes, Would Substantially Change MIPS

July 29, 2019

On July 29, 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 payment policies, including proposals related to the Quality Payment Program (QPP), online ahead of publication in the Federal Register on August 14. At the same time, CMS released the Hospital Outpatient Prospective Payment System (HOPPS) proposed rule for 2020, which is also available online ahead of publication in the Federal Register on August 9.

In the MPFS proposal, CMS estimates a 0% overall impact for both the hematology/oncology and radiation oncology specialties in 2020. Targeted cuts to oncology were limited to two drug administration codes—96360 and 96372—which were identified as misvalued in the 2018 final rule. It is important to note, however, that the actual impact on individual physician practices will depend on the mix of services the practice provides. Practices in certain states may also see a change, due to the elimination of the 1.0 floor previously applied to the work geographic pricing cost index.

CMS is also proposing to align Evaluation & Management (E&M) coding with changes laid out by the Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E&M visits. The proposed CPT coding changes retain five levels of coding for established patients, reduce the number of levels to four for E&M visits for new patients, and revise code definitions. The CPT changes would also revise the times and medical decision-making process for all of codes and requires performing a history and exam only as medically appropriate. The proposed changes would also allow clinicians to choose the E&M visit level based on either medical decision making or time. CMS is proposing to adopt the American Medical Association’s (AMA) Specialty Society Relative Value Scale (RVS) Update Committee’s (RUC) recommended values for the office/outpatient E&M visit codes for calendar year 2021 and the new add-on CPT code for prolonged service time. AMA RUC-recommended values would increase payment for office/outpatient E&M visits.

The rule also includes proposed changes to the Quality Payment Program (QPP) for 2020. ASCO is still analyzing the proposal and assessing its potential impact on the oncology community, but a key update for cancer care providers in the Merit-Based Incentive Payment System (MIPS)—one of QPP’s two tracks—in 2020 is in the weighting of performance categories and in the overall score needed to avoid a negative payment adjustment.

The 2020 QPP proposal would weight the MIPS Quality category at 40% of a provider or practice’s total MIPS score (down from 45% in 2019), Promoting Interoperability (formerly Advancing Care Information/Meaningful Use) would remain at 25%; Improvement Activity would remain at 15%; and the Cost category would increase to 20% (up from 15%) of the total MIPS score. The performance threshold is also slated to go up to 45 points (from 30 points) to avoid a negative payment adjustment, and the MIPS performance period will be 12 months starting January 1, 2020.

Further proposed changes for 2020 include scoring adjustments to the Promoting Interoperability performance category, an increase in the data completeness thresholds for quality performance category reporting, and an increase in group reporting requirements for the Improvement Activities performance category. CMS is also proposing to revise the specifications for the Total Per Capita Cost (TPCC) and Medicare Spending Per Beneficiary Clinician (MSPB Clinician) measures and add 10 episode-based cost measures.

In 2021 and beyond, CMS is proposing the creation of “MIPS Value Pathways” (MVPs), which would be “bundles” or “tracks” of care that connect measures and activities across the four MIPS performance categories. Included in these bundles would be Promoting Interoperability measures and a set of administrative claims-based quality measures focusing on population and public health priorities. CMS envisions that clinicians would participate in MIPS via one MVP that would include measures and activities from all four performance categories.

ASCO will continue to analyze the proposed rules and provide more information to members. ASCO will also provide comments to CMS during the open comment period, which closes on September 27.

Stay tuned to ASCO in Action for updates on this and other cancer policy developments.