CMS Finalizes Updates to E&M Codes, Establishes MIPS Value Pathways

November 1, 2019

On November 1, the Centers for Medicare & Medicaid Services (CMS) released its final rule for the 2020 Medicare Physician Fee Schedule (MPFS) and other changes to Medicare Part B reimbursement policies, including proposals related to the Quality Payment Program (QPP). The agency also released the Hospital Outpatient Prospective Payment System (HOPPS) final rule for 2020. Both rules are expected to publish in the Federal Register on November 9.

The estimated overall impact of the final MPFS rule for both the hematology/oncology and radiation oncology specialties is 0% in 2020. However, the actual impact on individual physician practices will depend on the mix of services the practice provides, and practices in certain states may see a change due to the elimination of the 1.0 threshold previously applied to the geographic practice cost indices (GPCIs).

CMS also finalized targeted cuts to oncology for two drug administration codes—96360 and 96372—which were identified as misvalued in the 2018 final rule. The agency also finalized provisions 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. Thus, there will be five levels of coding for established patients, four levels for E&M visits for new patients, and revised code definitions.

The final rule also revises the times and medical decision-making processes for all of codes and requires providers to perform a history and exam only as medically appropriate. Under the final rule, clinicians will also be allowed to choose the E&M visit level based on either medical decision making or time. CMS will be adopting 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. These recommended values will increase payment for office/outpatient E&M visits.

Furthermore, the rule finalizes updates 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 final rule will maintain all four MIPS performance categories at their 2019 weights:

Performance Category

2019

2020

Quality

45%

45%

Cost

15%

15%

Promoting Interoperability (formerly Advancing Care Information/Meaningful Use)

25%

25%

Improvement Activities

15%

15%

The performance threshold, which is the minimum total MIPS score needed to avoid a negative payment adjustment will increase to 45 points in 2020 (up from 30 points in 2019).

CMS also finalized its plan to establish “MIPS Value Pathways” (MVPs) beginning in 2021. CMS has characterized MVPs as a means to reduce the burden of participating in MIPS and for CMS to collect more meaningful performance data. The MVP framework would connect activities and measures from the four MIPS performance categories that are relevant to a patient population, a medical specialty, or a specific medical condition. CMS notes that MVPs may include, but will not be limited to, administrative claims-based population health, care coordination, patient-reported data (which may include patient reported outcomes, or patient experience and satisfaction measures), and/or specialty/condition-specific measures. ASCO will continue to engage with the agency as it implements this new provision.

ASCO will continue to evaluate all of the provisions in the final rule and will provide more information to members as it becomes available.

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