Finalized Policy, Payment, and Quality Provisions Changes to the Medicare PFS for CY 2020

On November 1, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) effective on or after January 1, 2020.

The calendar year (CY) 2020 PFS final rule is one of several rules that reflect a broader Administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation.

Background on the Physician Fee Schedule
Payment is made under the PFS for services furnished by physicians and other practitioners in all sites of service. These services include, but are not limited to, office visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services.

In addition to physicians, payment is made under the PFS to a variety of practitioners and entities, including nurse practitioners, physician assistants, and physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities.

Payments are based on the relative resources typically used to furnish the service. Relative value units (RVUs) are applied to each service for physician work, practice expense, and malpractice. These RVUs become payment rates through the application of a conversion factor. Payment rates are calculated to include an overall payment update specified by statute.

Payment ProvisionsS

CY 2020 PFS Ratesetting and Conversion Factor
We are finalizing a series of standard technical proposals involving practice expense, including the implementation of the 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).

With the budget neutrality adjustment to account for changes in RVUs, as required by law, the finalized CY 2020 PFS conversion factor is $36.09, a slight increase of $0.05 above the CY 2019 PFS conversion factor of $36.04.

Medicare Telehealth Services
For CY 2020, we are adding the following codes to the list of telehealth services: HCPCS codes G2086, G2087, G2088, which describe a bundled episode of care for treatment of opioid use disorders.

Evaluation and Management (E/M) Services
Consistent with our goal to reduce burden, we are aligning our E/M coding with changes adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits. The CPT coding changes retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients, and revise the code definitions. The CPT code changes also revise the times and medical decision making process for all of the codes, and requires performance of history and exam only as medically appropriate. The CPT code changes also allow clinicians to choose the E/M visit level based on either medical decision making or time.

We are adopting the AMA Specialty Society Relative Value Scale Update Committee (RUC) recommended values for the office/outpatient E/M visit codes for CY 2021 and the new add-on CPT code for prolonged service time. The AMA RUC-recommended values will increase payment for office/outpatient E/M visits. The RUC recommendations reflect a robust survey approach by the AMA, including surveying more than 50 specialty types, and demonstrating that office/outpatient E/M visits are generally more complex and require additional resources for most clinicians.

We are also strengthening the Medicare-specific payment for office/outpatient E/M visits for primary care and non-procedural specialty care that we finalized in the CY 2019 PFS final rule. We have simplified this payment by using a single add-on 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. This will be implemented in CY 2021.

We are not adopting changes to the global surgery codes, as we continue to evaluate data.

Physician Supervision Requirements for Physician Assistants (PAs)
We are updating our regulation on physician supervision of PAs to give PAs greater flexibility to practice more broadly in the current health care system in accordance with state law and state scope of practice. In the absence of any state rules, CMS is finalizing a revision to the current supervision requirement to clarify that physician supervision is a process in which a PA has a working relationship with one or more physicians to supervise the delivery of their health care services. Such physician supervision is evidenced by documenting the PA’s scope of practice and indicating the working relationship(s) the PA has with the supervising physician(s) when furnishing professional services.

Review and Verification of Medical Record Documentation
To reduce burden, we are finalizing broad modifications to the documentation policy so that physicians, physician assistants, and advanced practice registered nurses (APRNs – nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists) can review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, medical, physician assistant, and APRN students, nurses, or other members of the medical team.

Care Management Services
For CY 2020, we are finalizing our proposal to increasing payment for transitional care management (TCM) services which are care management services provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays.

We are creating a Medicare-specific code for additional time spent beyond the initial 20 minutes allowed in the current coding for chronic care management (CCM) services, which are services provided to beneficiaries with multiple chronic conditions over a calendar month.

Recognizing that clinicians across all specialties manage the care of beneficiaries with chronic conditions, we are also creating new coding for principal care management (PCM) services, for patients with only a single serious and high-risk chronic condition.

Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs)
Section 2005 of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) established a new Medicare Part B benefit for opioid use disorder (OUD) treatment services, including medications for medication- assisted treatment (MAT), furnished by opioid treatment programs (OTPs).

CMS is implementing this benefit beginning January 1, 2020, as required by the SUPPORT Act.

  • CMS is finalizing the definition of OUD treatment services which includes:
    • FDA-approved opioid agonist and antagonist treatment medications,
    • The dispensing and administering of such medications (if applicable),
    • Substance use counseling,
    • Individual and group therapy,
    • Toxicology testing which includes both presumptive and definitive testing,
    • Intake activities, and
    • Periodic assessments.
  • As required by the SUPPORT Act, SAMHSA certification is required as part of the enrollment policy and process for OTPs. Additionally, CMS is finalizing that OTPs that have been fully and continuously certified by SAMHSA since October 23, 2018 will be assigned to the “moderate risk” level of categorical screening, OTPs that have not been fully and continuously certified by SAMHSA since that date will be assigned to the “high risk” screening level.
  • CMS is finalizing bundled payment rates for OTPs based on the medication administered for episodes of care for a period of one week in duration. The bundled payment rate is based on a drug and non-drug component, and is stratified into several codes to account for differences in beneficiaries’ clinical needs. CMS also finalized an increased payment rate for the non-drug component of the bundled payment rate and add-on codes for intake activities, periodic assessments and take-home doses of drugs.
  • For the drug component of the OTP bundle, CMS finalized a payment of average sales price (ASP) percent for a drug, when ASP data are available. For methadone, CMS will use TRICARE pricing when ASP is not available. For oral buprenorphine, CMS is finalizing using National Average Drug Acquisition Cost pricing when ASP data are not available.
  • CMS is finalizing a policy to allow counseling and therapy services described in the bundled payments, to be furnished via two-way interactive audio-video communication technology as clinically appropriate; and
  • CMS is also finalizing that there will be zero beneficiary copayment for 2020.

OTP providers must enroll in Medicare to receive Medicare payment for these services.

Additional information on how to enroll in Medicare is available at the CMS Opioid-Treatment-Program-Center page.

Bundled Payments under the PFS for Opioid Use Disorders

A bundled payment for the management and counseling for OUD, will create an avenue for clinicians to bill for a group of services in the office setting similar to the services being paid for under the new OTP benefit for opioid treatment program clinics. CMS is finalizing the creation of new coding and payment for a monthly bundle of services for the treatment of OUD that includes overall management, care coordination, individual and group psychotherapy, and substance use counseling, as well as an add-on code for additional counseling. 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. CMS will consider coding and payment amounts that recognize different levels of patient need and different types of practice arrangements for future rulemaking, including use of MAT in the emergency department setting.

Therapy Services
In the CY 2019 PFS final rule, to implement the statutory requirements regarding therapy assistants, CMS established modifiers to identify therapy services that are furnished in whole or in part by physical therapy (PT) and occupational therapy (OT) assistants, and set a de minimis 10 percent standard for when these modifiers will apply to specific services.

Other Provisions

Ambulance Services
To reduce provider/supplier burden and in response to stakeholder comments, CMS is clarifying that there is no CMS-prescribed form for certification statements for ambulance transports. Ambulance suppliers and providers are free to choose the format by which the required information is displayed. We made clear that forms, which are required in fulfilling other legal requirements associated with transports, may also satisfy the function of the certification statement. CMS is also granting ambulance suppliers and providers greater flexibility around who may sign a non-physician certification statement in certain circumstances. CMS is adding licensed practical nurses (LPNs), social workers and case managers to the list of staff members who may sign the non-physician certification statement if the provider/supplier is unable to obtain the attending physician’s signature.

Ground Ambulance Data Collection System
The Bipartisan Budget Act (BBA) of 2018 requires the Secretary to develop a data collection system to collect cost, revenue, utilization, and other information determined appropriate with respect to ground ambulance providers and suppliers. CMS is finalizing the data collection format and elements with some modifications based on comments received. CMS is also finalizing a sampling methodology that CMS will use to identify ground ambulance organizations for reporting each year through 2024 and not less than every 3 years after 2024, as well as the data collection and reporting timeframes that selected ground ambulance organizations will need to satisfy. Ground ambulance organizations that are selected to report, but fail to sufficiently submit the required data, will be applied a 10% reduction to payments made under the Ambulance Fee Schedule unless they are granted a hardship exemption by CMS.

Open Payments Program
CMS’s Open Payments program promotes a transparent and accountable healthcare system by annually publishing the financial relationships that physicians and teaching hospitals (known as “covered recipients”) have with applicable manufacturers and group purchasing organizations (GPOs). The program has been successful in disclosing over 64 million records since August of 2013. CMS continues to make adjustments to the program to reflect new statutory requirements and stakeholder feedback. Therefore, CMS is proposing several changes to Open Payments: 1) expanding the definition of “covered recipient;” (as required by the SUPPORT Act) 2); modifying payment categories; and 3) standardizing data on reported medical devices.

Medicare Shared Savings Program
CMS appreciates the comments received on how to potentially align the Medicare Shared Savings Program quality performance scoring methodology more closely with the Merit-based Incentive Payment System (MIPS) quality performance scoring methodology And will consider these for future rulemaking. We recognize that accountable care organizations (ACOs) and their participating providers and suppliers dedicate resources to performing well on quality metrics. We believe that aligning quality metrics across programs will reduce burden and will allow ACOs to more effectively target their resources toward improving care. We are finalizing refinements to updating the Shared Savings Program measure set by reverting two measures to pay-for- reporting for a limited time due to substantive changes.

We finalized refinements to the Shared Savings Program measure set by: 1) reverting ACO 43: Ambulatory Sensitive Condition Acute Composite (AHRQ) Prevention Quality Indicator ((PQI) #91) (version with additional risk adjustment) measure to pay-for- reporting for performance years 2020 and 2021 due to a substantive change made by the measure owner, 2) maintain ACO-17: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention as pay-for-reporting for performances year 2019 as the Quality Payment Program is finalizing a substantive change update to the numerator guidance to the measure, and 3) not finalizing to remove ACO-14; Preventive Care and Screening: Influenza Immunization and replace it with the Adult Immunization Status measure in the CMS Web Interface as finalized under the Quality Payment program.