CMS Releases 2020 Proposed Physician Fee Schedule Rule

August 2019 ~

CMS, on July 29, released its proposed rule on the 2020 Medicare physician fee schedule (PFS) and Quality Payment Program (QPP) performance period. In addition to proposals to increase the conversion factor by a nickel to $36.09, the rule includes proposals on Medicare payments to support opioid treatment programs (OTPs).

The policy changes proposed in the 2020 PFS have been designed to ensure clinicians spend more time providing high-value care for patients instead of filing cumbersome paperwork, according to CMS. The agency says these changes will help reduce burden, remove unnecessary measures and making it easier for them to be on the path towards value-based care, and will better account for the time clinicians spend with patients. A summary of these proposals can be seen below.


CY 2020 PFS Rate-Setting and Conversion Factor
CMS is proposing 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 proposed CY 2020 PFS conversion factor is $36.09 -a slight increase above the CY 2019 PFS conversion factor of $36.04.

Medicare Telehealth Services
CMS is proposing to add the following HCPCS codes (describing a bundled episode of care for treatment of opioid use disorders) to the list of telehealth services:

  • GYYY1
  • GYYY2
  • GYYY3

Payment for Evaluation and Management (E/M) Services
CMS is also proposing to align E/M coding with changes laid out by the CPT Editorial Panel for office/outpatient E/M visits. These 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. According to CMS, the 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 changes will also allow clinicians to choose the E/M visit level based on either medical decision making or time.

The agency is proposing to adopt the AMA 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 would increase payment for office/outpatient E/M visits.  The RUC recommendations reflect a robust survey approach by the AMA, including surveying over 50 specialty types demonstrate that office/outpatient E/M visits are generally more complex and require additional resources for most clinicians.

CMS has also proposed the consolidation of the Medicare-specific add-on code for office/outpatient E/M visits for primary care and non-procedural specialty care that was finalized in the CY 2019 PFS final rule for implementation in CY 2021 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.

Physician Supervision Requirements for Physician Assistants (PAs)
CMS is proposing to modify the 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 State law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA’s approach to working with physicians in furnishing their services.

Review and Verification of Medical Record Documentation 
Following feedback from the clinician community in response to the Patients Over Paperwork initiative request for information (RFI), CMS is proposing broad modifications to the documentation policy so that physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives could review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, nurses, students, or  other members of the medical team.

Care Management Services

The proposal also includes an increase in payment for Transitional Care Management (TCM), which is a care management service provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays.

CMS is proposing a set of Medicare-developed HCPCS G codes for certain Chronic Care Management (CCM) services -a service for providing care coordination and management services to beneficiaries with multiple chronic conditions over a calendar month service period. The agency suggests replacing a number of the CCM codes with Medicare-specific codes to allow clinicians to bill incrementally to reflect additional time and resources required in certain cases and better distinguish complexity of illness as measured by time.  Additionally, the agency is proposing an adjustment to certain billing requirements and elements of the care planning services.

The agency is also hoping to create new coding for Principal Care Management (PCM) services, which according to CMS, would pay clinicians for providing care management for patients with a single serious and high-risk condition.

Comment Solicitation on Opportunities for Bundled Payments under the PFS
CMS is seeking comment on opportunities to expand the concept of bundling to improve payment for services under the PFS and more broadly align PFS payment with the broader CMS goal of improving accountability and increasing efficiency in paying for the health care of Medicare beneficiaries.

Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) 
To meet the statutory requirements of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, CMS is specifically proposing:

  • Definitions of OTP and OUD treatment services;
  • Enrollment policies for OTPs;
  • Methodology and estimated bundled payment rates for OTPs that vary by the medication used to treat OUD and service intensity, and by full and partial weeks;
  • Adjustments to the bundled payments rates for geography and annual updates;
  • Flexibility to deliver the counseling and therapy services described in the bundled payments via two-way interactive audio-video communication technology as clinically appropriate; and
  • Zero beneficiary copayment for a time-limited duration.

CMS intends to implement this benefit beginning January 1, 2020.

Bundled Payments under the PFS for Substance Use Disorders
CMS is proposing new coding and payment for a bundled episode of care for management and counseling for OUD.  According to the agency, 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.

One code will describe the initial month of treatment, which would include administering assessments and developing a treatment plan. The other code would describe subsequent months of treatment, and an add-on code describes additional 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.

Therapy Services

The agency is proposing a policy to implement modifiers that identify therapy services that are furnished in whole or in part by physical therapy (PT) and occupational therapy (OT) assistants, as required by statute, and apply the 10 percent de minimis standard, while imposing the minimum amount of burden for those who bill for therapy services while meeting the requirements of the statute.


Ambulance Services
CMS is proposing to clarify that there is no CMS-prescribed form for physician certification statements (PCSs) for ambulance transports. So long as the elements required by regulation are clearly conveyed, ambulance suppliers and providers would be free to choose the format by which the information is displayed, and they may find that other forms that may be required by other legal requirements to perform the transport may also satisfy the function of the PCS, according to the announcement.

The agency is also proposing to grant ambulance suppliers and providers greater flexibility around who may sign a non-physician certification statement in certain circumstances.  The proposal would also add licensed practical nurses (LPNs), social workers and case managers as staff members who may sign the non-physician certification statement if the provider/supplier is unable to obtain the attending physician’s signature within 48 hours of the transport.

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 concerning ground ambulance providers suppliers. The agency has proposed that the data collection format and elements utilize a sampling methodology that CMS would use to identify ground ambulance organizations for reporting each year through 2024 and not less than every 3 years after 2024 and reporting timeframes.

CMS is also proposing to reduce by 10% the payments that would otherwise be made to a ground ambulance organization that is identified for reporting but fails to sufficiently submit data, as well as a process under which a ground ambulance organization can request a hardship exemption that, if granted by CMS, would allow it to avoid the payment reduction.

Open Payments Program
CMS is proposing several changes to the Open Payments program:

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 soliciting comment on how to potentially align the Medicare Shared Savings Program (MSSP) quality performance scoring methodology more closely with the Merit-based Incentive Payment System (MIPS) quality performance scoring methodology.

Additionally, CMS is proposing to refine the MSSP measure set by:

1) removing one measure and adding another to the CMS Web Interface, to maintain alignment with proposals under the Quality Payment Program, and

2) reverting one measure to pay-for-reporting due to a substantive change made by the measure owner.

Stark Advisory Opinion Process
CMS is also seeking additional comments on potential changes to its advisory opinion process to address stakeholder comments received from last year’s Request for Information (RFI) on how to address unnecessary burden created by the Stark physician self-referral law (Section 1877 of the Social Security Act).

As seen in the announcement, the CY 2020 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation. CMS expects the proposed PFS to save 2.3 million hours per year in burden reduction.

Comments in response to the proposed rule can be submitted to CMS until 5:00 p.m. on September 27.

For more information, see the press release and the CMS fact sheet.

For complete details and to see the proposal in its full text, refer to the CY 2020 Physician Fee Schedule and Quality Payment Program Proposed Rule.

Source(s): CMS; Federal Register; MedPage Today; Policy & Medicine; American Academy of Family Physicians;