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

The Centers for Medicare and Medicaid Services (CMS) recently published the final draft of the Medicare Physician Fee Schedule (PFS) for 2020. At the heart of the MPFS is the annual conversion factor update. After legislatively mandated adjustments, the 2020 conversion factor will be $36.09, a slight increase above the 2019 PFS conversion factor of $36.04.

In addition to changing the payment rates for 2020, the Final Rule also mandates 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 finalized 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 will undo the 2018 rule, which rolled up levels 2 through 4 for established and new patients into a single rate with similar documentation requirements beginning in 2021. Instead, CMS will adopt 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 finalized policies, 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 will 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:

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. However, in the 2020 final rule, CMS consolidated 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. That single add-on code will be reflected with a new CPT code (CPT 99xxx) rather than GPRO1, which was adopted in 2019 for use beginning in 2021, and CPT codes 99358 and 99359 (prolonged non-face-to-face). 

CMS has not modified any other E/M code sets at this time; 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 accepted the recommended updates for the work values.

According to the American College of Emergency Physicians (ACEP), the expected impact of these changes is 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 ACEP, when the increases were first proposed.

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 continued to modify 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 created 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 sought comments 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 final 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) were finalized 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 have reduced the Quality performance category weight from 45 percent in 2019 down to 40 percent in 2020, with the hope of moving toward 30 percent by 2022. Alternately, the proposed rule would have increased the Cost performance category weight up from 15 percent in 2019 to 20 percent in 2020, to achieve 30 percent by 2022. These changes would have helped 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). However, CMS did not approve the proposed changes and instead kept the performance category weighting the same for 2020.

Performance categories will be weighted as follows for 2020, representing no change from 2019:

• Quality = 45%
• Cost = 15%
• Promoting Interoperability = 25%
• Improvement Activities = 15%

Performance Threshold and Payment Adjustments

Also for the 2020 performance period, the performance threshold will be 45 points, and the exceptional performance threshold would be 85 points, up from 30 and 75 points in 2019. For 2021, the performance threshold will be set at 60 points, and the exceptional performance threshold will remain 85 points. As well, in 2020, the MIPS program will 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 Category Updates

Among the various performance categories, the following updates and changes have been finalized 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 called 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. 

MIPS Value Pathways

Finally, CMS finalized a new program for MIPS participation called MIPS Value Pathways (MVPs). The program is described as “a conceptual participation framework” that will be in effect for the 2021 performance year. MVPs will 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 will 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 recognize that this will be a significant shift in the way clinicians may potentially participate in MIPS, therefore we want to work closely with clinicians, patients, specialty societies, third parties and others to establish the MVPs,” CMS said in the final rule. “We want to continue developing the future state of MIPS together with each of you to ensure that we are reducing burden, driving value through meaningful participation, and, most importantly, improving outcomes for patients.”

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

For More Information

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

• 2020 Physician Fee Schedule Quality Payment Program Final Rule (CMS 1715-F) (full text)
• 2020 Physician Fee Schedule Quality Payment Program Final Rule Supporting Documents
• CMS’ Finalized Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2020 Fact Sheet
• CMS’ 2020 Quality Payment Program Final Rule Overview Fact Sheet (automatic download from CMS)
• Fierce Healthcare’s “CMS finalizes physician fee schedule rule with cuts to physical therapists, psychologists”
• Healthcare Dive’s “Final physician payment rule keeps E/M code changes”

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