Medicare Physician Fee Schedule Final Rule 2020 – What practices need to know
The Centers for Medicare & Medicaid Services (CMS) published its 2020 Medicare Physician Fee Schedule Final Rule on November 15, 2019. CMS estimates that total allowed charges under the Medicare Physician Fee Schedule for all specialties will exceed $93 billion in 2020, which includes approximately $2.2 billion for nephrology, $1.9 billion for hematology/oncology, $1.8 billion for radiation oncology and radiation therapy centers, and $500 million for rheumatology.
Here are some of the key provisions that will impact physician practices in 2020:
New Medicare Reimbursement for Principal Care Management
Since 2015, Medicare has reimbursed physicians for chronic care management (CCM) furnished to beneficiaries with multiple chronic conditions. CCM involves non-face-to-face services furnished by clinical staff under general supervision of the billing practitioner, pursuant to a written care plan. These services include, for example, care coordination, medication reconciliation, and patient education. Generally, CCM is intended for the long-term management of high-cost patients by primary care providers.
Effective January 1, CMS will reimburse for principal care management (PCM) furnished to beneficiaries with a single chronic condition. The following identifies the key differences between CCM and PCM services:
Chronic Care Management | Principal Care Management | |
---|---|---|
Base CPT/HCPCS code |
99490 |
G2065 |
Total RVU/Payment |
1.17/$42.22 |
1.10/$39.70 |
Time Requirement (services furnished by clinical staff under general supervision) |
20 minutes/month |
30 minutes/month |
Number of Chronic Conditions |
2 or more |
1 |
Billing Practitioner (most cases) |
Primary Care Provider |
Specialist |
Scope of Service |
Manage total patient care |
Manage disease-specific care |
Likely Trigger |
General need for care coordination, communication |
Exacerbation of condition or hospitalization |
Intended Length of Time |
Longer-term, as needed |
Shorter-term, until condition is stabilized |
Note: these summarizations are not strict service requirements, rather, a brief summarization of intended use of the codes based on various readings of CMS regulatory guidance and other materials.
Concerned about paying for duplicative services, CMS includes two additional requirements for PCM: (1) the practitioner billing for PCM must document in the patient’s record ongoing communication and care coordination between all practitioners furnishing care to the beneficiary, and (2) the practitioner cannot bill for interprofessional consultations or other care management services (excluding remote patient monitoring for the same beneficiary for the same time period as PCM).
As with CCM, CMS will reimburse for PCM services furnished directly by a physician or non-physician practitioner (as opposed to clinical staff under general supervision) under HCPCS code G2064. Payment will be $78.68 for 30 minutes or more of care management services.
PCM becomes a strong alternative to CCM for specialists engaged in care management activities. CCM has always been challenging for specialists as they often only manage one (or a subset) of a patient’s chronic conditions. With PCM, that focus becomes the purpose—shorter-term care management of a single chronic condition—and specialists will likely find it easier to meet the code’s billing requirements.
Merit-Based Incentive Payment Program (MIPS)
After proposing otherwise, CMS has decided to assign the same weights to the four MIPS performance categories as it did in 2019:
- Quality – 45 percent
- Improvement Activities – 15 percent
- Promoting Interoperability – 25 percent
- Cost – 15 percent
By statute, Cost must be increased to 30 percent and Quality must be reduced to 30 percent by 2022.
In 2020, the minimum performance score required to avoid any MIPS penalty will increase from 30 to 45 points. In 2021, it will increase to 60 points. The threshold to qualify for the exceptional performance payment will increase from 75 to 85 points in 2020 and 2021. Finally, the maximum incentive payment and penalty will increase to 9 percent in 2020.
In 2020, there will be 20 measures in the Cost category: the Medicare Spending Per Beneficiary measure, the Total Per Capita Cost measure, and eighteen episode-based measures. CMS is adding 10 new episode based measures, including a new measure for lumpectomy, partial mastectomy and simple mastectomy.
In the Final Rule, CMS discussed at length its intent to expand the number of episode-based measures in future years to include more specialties, including the process for developing and validating those measures.
CMS will calculate a Cost score based on a combination of all the Cost measures for which a physician or group qualifies. However, CMS will not calculate a score in the Cost category if the physician or group does not meet the case minimum for at least one of the measures. In those cases, the 15 percent Cost category weight will be transferred to the Quality category, raising the percentage from 45 percent to 60 percent.
MIPS Value Pathways
This summer, CMS proposed an updated framework for MIPS called MIPS Value Pathways, or MVPs. The proposed MVPs are best described as condition- or specialty-specific groups of cost, quality, and improvement measures. Measures would be pre-selected and grouped for providers, to relieve the burden of choice and re-focus the program on the most important health priorities (i.e., quality over quantity).
In the Final Rule, CMS affirmed its intent to move forward with MVPs, with at least some MVPs defined and available for reporting in 2021. However, CMS offered no additional details, other than to state its intent to engage stakeholders in the MVP development process.
Conversion Factor
RVU Updates
Highest Increases | Highest Reductions | ||
Clinical Social Worker | 4% | Ophthalmology | -4% |
Clinical Psychologist | 3% | Diagnostic Testing Facility | -3% |
Podiatry | 2% | Neurology | -2% |
Optometry | -2% | ||
Cardiac Surgery | -2% | ||
Vascular Surgery | -2% |
Source: CY2020 Medicare Physician Fee Schedule Final Rule, Table 119.
2021 E/M Changes
CMS remains on track to overhaul documentation and payment policies for evaluation and management (E/M) services. Effective January 1, 2021, CMS will adopt revised E/M code definitions developed by the AMA CPT Editorial Panel. CMS also intends to pay for each level of service rather than utilize a blended rate and to adopt revised work and practice RVU inputs for E/M services.
CMS included in the Final Rule its estimated impact of the E/M changes on specific specialties’ total allowed charges in 2021, which range from a 16 percent increase for endocrinologists to a 10 percent decrease for ophthalmologists.
Highest Increases | Highest Reductions | ||
Endocrinology | 16% | Ophthalmology | -10% |
Rheumatology | 15% | Chiropractor | -9% |
Hematology/Oncology | 12% | Nurse Anesthetist | -9% |
Family Practice | 12% | Cardiac Surgery | -8% |
Urology | 8% | Pathology | -8% |
Neurology | 8% | Radiology | -8% |
Interventional Pain Management | 8% | Physical/Occupational Therapy | -8% |
General Practice | 8% | Radiation Oncology & Radiation Therapy Centers | -4% |
Nurse Practitioner | 8% |
Source: CY2020 Medicare Physician Fee Schedule Final Rule, Table 120.
November 2019
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