2020 Physician Fee Schedule Final Rule Released

November 2019 ~

On November 1, CMS released the final 2020 Physician Fee Schedule (PFS). The finalized rule includes payment rate updates, modifications, and quality provisions for services furnished under to the Merit-based Incentive Payment System (MIPS) reporting requirements and alternative payment model (APM) participation options starting January 1, 2020.


CY 2020 PFS Rate-setting and Conversion Factor
CMS will implement a slight increase of $0.05 above the CY 2019 PFS conversion factor of $36.04. The PFS conversion factor for CY 2020 is $36.0896. The CY 2020 national average anesthesia conversion factor will be $22.2016.

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

Evaluation and Management (E/M) Services
The CY 2020 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.

CMS is adopting the American Medical Association (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 agency also simplified Medicare-specific payment for office/outpatient E/M visits for primary care and non-procedural specialty care (finalized in the CY 2019 PFS final rule) 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.

CMS notes that the agency will not be adopting changes to the global surgery codes for CY2020, as data evaluation is still in-progress.

Physician Supervision Requirements for Physician Assistants (PAs)
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
CMS is 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, CMS is 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, the agency is 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)
CMS is implementing the Medicare Part B benefit for opioid use disorder (OUD) treatment services, including medications for medication- assisted treatment (MAT), furnished by opioid treatment programs (OTPs) beginning January 1, 2020, as required by Section 2005 of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (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.

Bundled Payments under the PFS for Opioid Use Disorders
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.


Ambulance Services
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. 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
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 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 is 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.

The agency has 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.

For More Information on the 2020 PFS Final Rule, see the Press Release, Treatment for Opioid Use Disorder Press Release, and the Quality Payment Program Fact Sheet.



Source(s): CMS MLN Connects, Special Edition, Friday, November 1, 2019; MGMA Washington Connection-Regulatory Alert; CMS Fact Sheet;