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2020 Proposed Medicare Physician Fee Schedule: What Emergency Physicians Need to Know

2020 Proposed Medicare Fee Schedule: What Emergency Physicians Need to Know

The Centers for Medicare and Medicaid Services (CMS) recently published the proposed Medicare Physician Fee Schedule (PFS) for 2020. At the heart of the proposal is the annual conversion factor update. After legislatively mandated adjustments, the proposed conversion factor is $36.0896, a slight increase above the 2019 PFS conversion factor of $36.0391.

In addition to changing the payment rates for 2019, the Proposed Rule also recommended changes to several payment policies. We’ve highlighted a few of the biggest changes that would be most interesting to emergency physicians.

E/M Changes

One of the biggest changes proposed by CMS is an overhaul of office/outpatient E/M visits, which according to a recent Medicare Learning Network call, account for 20 percent of all PFS dollars. In effect, CMS is proposing to undo last year’s rule, which rolled up levels 2 through 4 for established and new patients into a single rate with similar documentation requirements beginning in 20121. Instead, CMS has proposed adopting the changes in description and documentation guidelines the American Medical Association has made to the CPT codes for office/outpatient E/M visits.

According to the CMS Fact Sheet on the proposed changes, the new CPT guidelines retain 5 levels of coding for established patients and reduce the number of levels to 4 for office/outpatient E/M visits for new patients. The CPT changes also revise the times and medical decision making process for all of the codes, allow clinicians to choose the E/M visit level based on either medical decision making or time, and require performance of history and exam only as medically appropriate. 

As well as, CMS proposes to adopt the AMA RVS Update Committee (RUC)-recommended updated values for the office/outpatient E/M visit codes, which will increase payments for these services. See the chart below for how these changes could broadly affect payments before geographic adjustments:

Level (New Patients)Current Payment* (new patient) Approximate Payment Rates Finalized in 2019 for 2021 Proposed Payment**
Level (Established Patients)Current Payment* (established patient) Approximate Payment Rates Finalized in 2019 for 2021 Proposed Payment**

*Current Payment for CY2019
**Proposed Payment based on the CY2020 proposed relative value units and the CY2019 payment rate

The 2019 final rule also included two add-on codes for use beginning in 2021 to describe the additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care, and another set to indicate an extended visit. In the 2020 proposed rule, CMS hopes to consolidate those add-on codes into a single code describing the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. As well, CMS is proposing to use the new CPT code (CPT 99xxx) for prolonged services that extend time beyond in lieu of GPRO1 (the extended service code), which was adopted in 2019 for use beginning in 2021, and CPT codes 99358, 99359 (prolonged non-face-to-face). Payment for the add-on code for complex cases would be $17, and the payment for the prolonged services code would be $35.

CMS currently has no proposals for modifying other E/M code sets; however, in the 2018 Medicare PFS final rule, CMS nominated emergency department E/M codes for review as potentially misvalued, “suggesting that the work RVUs for emergency department visits may not appropriately reflect the full resources involved in furnishing these services.” As a result, 99281-99285 also were evaluated by the AMA RUC Committee, and for the 2020 Medicare PFS, CMS  has proposed to accept the recommended updates for the work values.

LevelOld Work RVUsNew Work RVUs

The expected impact of these changes would be a 1 percent growth of allowed charges.

“If finalized, this revaluation would increase Medicare reimbursement for ED visit codes by approximately $137 million in 2020,” said Jeffrey Davis, the Director of Regulatory Affairs at the American College of Emergency Physicians (ACEP).

The outlook may not be so rosy for 2021, however. Because RVU revaluations must remain budget neutral in the PFS, the high-volume utilization by most medical specialties of the office and outpatient E/M codes, which will receive their RVU updates for 2021, will mean substantial budget neutrality adjustments. According to ACEP, any specialty that does not regularly use the office/outpatient codes will likely see decreases in total allowed charges in 2021. However, there may still be hope for emergency physicians.

“Because there has been a longstanding acceptance that there should be rank order between the office and ED E/M codes, there is a chance for further positive adjustments to the ED E/M codes to maintain that balance going forward,” ACEP said.

Documentation Guidelines

Building off last year’s rule, CMS also hopes to continue modifying documentation policies so that physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives can 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.

Coverage for Opioid Use Disorder Treatment

In order to combat the continuing opioid epidemic, CMS has proposed the creation of new coding and payment for a bundled episode of care for management and counseling for opioid use disorder (OUD). The new proposed codes describe a monthly bundle of services for the treatment of OUD that includes overall management, care coordination, individual and group psychotherapy, and substance use counseling. CMS is proposing that the individual psychotherapy, group psychotherapy, and substance use counseling included in these codes could be furnished as Medicare telehealth services using communication technology as clinically appropriate.

As well, CMS is seeking comment on the use of medication-assisted treatment (MAT) in the ED in order to better understand typical practice patterns and to help determine whether the separate payment for such services in the ED would be justified in future years.

“We understand that in some cases, OUD can first become apparent to practitioners in the emergency department setting,” CMS said in the proposed rule. “We recognize that there is not specific coding that describes diagnosis of OUD or the initiation of, or referral for, MAT in the emergency department setting.”

Quality Payment Program MIPS

Several updates to the MIPS program for the 2020 reporting year (2022 payment year) are being proposed according to previously published implementation plans, as well as a new MIPS Value Pathways program to simplify MIPS participation.

Quality and Cost Performance Category Weighting

The proposed rule would reduce the Quality performance category weight to 40 percent in 2020, 35 percent in 2021, and 30 percent in 2022, down from 45 percent in 2019. Alternately, the proposed rule would increase the Cost performance category weight to 20 percent in 2020, 25 percent in 2021, and 30 percent in 2022, up from 15 percent in 2019. These changes help to achieve mandated equal weighting of the Quality and Cost performance categories, which is required by law beginning with the sixth year of the program (2022 performance year). 

Performance Category2019202020212020
Promoting Interoperability25%25%25%25%
Improvement Activities15%15%15%15%

Performance Threshold and Payment Adjustments

Also for the 2020 performance period, the performance threshold would be 45 points, and the exceptional performance threshold would be 80 points, up from 30 and 75 points in 2019. For 2021, the performance threshold would be set at 60 points, and the exceptional performance threshold would be set at 85 points. As well, in 2020, the MIPS program would reach the maximum negative payment adjustment of -9 percent, with positive payment adjustments up to a factor of 9 percent, although the budget neutrality mandate could mean an adjustment above or below 9 percent. The payment adjustment percent for 2019 was 7. 

Performance PeriodPerformance ThresholdExceptionalPerformance BonusPayment Adjustment
2017370Up to +/- 4%
20181570Up to +/- 5%
20193075Up to +/- 7%
20204580Up to +/- 9%
20216085Up to +/- 9%

Performance Category Updates

Among the various performance categories, the following updates and changes are proposed for 2020 and beyond:

  • Quality: Remove low-bar, standard of care, process measures, focus on high-priority outcome measures, and add new specialty sets (Speech Language Pathology, Audiology, Clinical Social Work, Chiropractic Medicine, Pulmonology, Nutrition/Dietician, and Endocrinology). CMS also is proposing to remove the following measures from the ED Measure set: 91 – Acute Otitis Extema (AOE): Topical Therapy and 255 – Rh Immunoglobulin Medicare (Rhogam) for Rh-Negative Pregnant Women at Risk of Fetal Blood Exposure. Data completeness requirements also would increase to 70 percent for 2020, up from 60 percent in 2019.
  • Cost: Add 10 episode-based measures and revise current global measures’ attribution methodologies (TPCC and MSPB Clinician).
  • Improvement Activities: New requirement for Improvement Activity credit for groups (at least 50% of MIPS eligible clinicians participate). Also, update measures with the addition of 2 new Improvement Activities, modification of 7 existing Improvement Activities, and removal of 15 existing Improvement Activities.
  • Promoting Interoperability: New reweighting standards for hospital-based MIPS eligible clinicians in groups. A group would be identified as hospital-based and eligible for reweighting if more than 75 percent of the NPIs in the group meet the definition of a hospital-based individual MIPS eligible clinician. In previous years, 100 percent had to be hospital-based. Non-patient facing groups (more than 75 percent of the MIPS eligible clinicians in the group are classified as non-patient facing) would automatically have the Promoting Interoperability performance category reweighted.

ACEP is calling the change in reweighting standards for hospital-based ED groups “a major victory.” 

“We have repeatedly argued that this ‘all or nothing rule’ is unfair and penalizes hospital-based clinicians who work in multi-specialty groups,” ACEP wrote on its website. “In this year’s rule, CMS is proposing to modify this policy by exempting groups from the Promoting Interoperability category of MIPS if 75 percent of the individuals in the group meet the definition of hospital-based.”

MIPS Value Pathways

Finally, CMS is proposing a new program for MIPS participation called MIPS Value Pathways (MVPs). The program is described as “a conceptual participation framework” that would be in effect for the 2021 performance year. MVPs would help move MIPS “away from siloed activities and measures and … towards an aligned set of measure options more relevant to a clinician’s scope of practice that is meaningful to patient care.”

In effect, the MVP framework would do three things:

  • Unite and connect measures and activities across the Quality, Cost, Promoting Interoperability, and Improvement Activities performance categories of MIPS
  • Incorporate a set of administrative claims-based quality measures that focus on population health/public health priorities
  • Streamline MIPS reporting by limiting the number of required specialty or condition specific measures

“We believe this combination of administrative claims-based measures and specialty/condition specific measures would streamline MIPS reporting, reduce complexity and burden, and improve measurement,” CMS officials said in the fact sheet about the proposal.

CMS has created a collection of illustrative diagrams (automatic download from CMS) to help explain the changes that the MVP framework would bring.

For More Information

For more information about the 2020 Medicare Physician Fee Schedule Proposed Rule and the 2020 Quality Payment Program Proposed Rule, check out the following resources:

Submit Your Comments

If you wish to submit comments about these or other issues in the proposed Medicare Physician Fee Schedule, CMS offers the following instructions:

In commenting, please refer to file code CMS-1715-P. Because of staff and resource limitations, CM cannot accept comments by FAX transmission. Comments, including mass comment submissions, must be submitted in one of the following three ways (please choose only one of the ways listed):

  • Electronically. You may submit electronic comments on this regulation to http://www.regulations.gov. Follow the “Submit a comment” instructions.
  • By regular mail. You may mail written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1715-P, P.O. Box 8016, Baltimore, MD 21244-8016. Please allow sufficient time for mailed comments to be received before the close of the comment period.
  • By express or overnight mail. You may send written comments to the following address ONLY: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1715-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Be sure to submit your comments to CMS by no later than 5 p.m. on September 27, 2019.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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