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Medicare’s CY 2020 Physician Fee Schedule Proposal



The Centers for Medicare and Medicaid Services (CMS) released its proposal for the calendar year (CY) 2020 Physician Fee Schedule (PFS) on July 29, 2019.

The American Association of Orthopaedic Surgeons (AAOS) will provide a lengthy summary of the proposal and a response in the near future. In the meantime, TOA has provided a summary for its members. TOA members will receive a lengthy summary in the TOA member e-mail.

Click here to view CMS’s proposal:

Payment for Evaluation/Management Services
Last summer’s proposal by CMS to reduce the number of E/M codes generated the greatest controversy in the CY 2019 PFS rule proposal. CMS’s original plan was to collapse four of the E/M levels – levels 2 through 5 – into a single, blended rate. After pushback from stakeholders, CMS finalized the CY 2019 proposal by blending E/M levels 2 through 4 and keeping levels 1 and 5.

The CY 2020 proposal, which can be found on page 491, would completely eliminate the blended rate for levels 2 through 4. Instead, the proposal would adjust E/M payments based on recommendations from the American Medical Association’s two committees:

    • Keep the same five levels for established patients.
    • Four levels for new patients.

The new proposal would also allow physicians to choose the E/M level based on either medical-decision making or time.

CMS also proposed recommendations made by the AMA’s Relative Value Scale Update Committee (RUC) for CY 2021:

    • New, increased values recommended by RUC for office/outpatient E/M codes.
    • A new add-on CPT code for prolonged service time. More information can be found on page 503, and this would result in 15 minutes beyond the highest level of service when time is used to select a visit level. (The add-on would be triggered at 55 minutes for a level 99215, and 75 minutes for a level 99205.)

Global Surgery Codes
CMS eliminated the 10- and 90-day global packages in the CY 2017 and CY 2018 payment rules (they were turned into 0-day packages). CMS stated that many of these packages were over-valued, and many orthopaedic services were referenced.

Congress re-instated 10- and 90-day global packages in the legislation that created MACRA with the stipulation that CMS must collect data on the packages. (Texas was not included in the data collection.)

CMS is not proposing to make changes to the global surgery codes in the CY 2020 proposal. However, CMS did release three reports that were prepared by RAND, and CMS is asking stakeholders to comment on these reports. The RAND reports can be found on page 520.

Per CMS:

RAND analyzed the data collected from the post-operative visits through this claim-based reporting for the first year of reporting, July 1, 2017 – June 30, 2018. They found that only 4 percent of procedures with 10-day global periods had any post-operative visits reported. While 71 percent of procedures with 90-day global periods had at least one associated postoperative visit, only 39 percent of the total post-operative visits expected for procedures with 90-day global periods were reported.

(A complete report on this is available here).

In addition to the claims-based data collection, RAND collected data on the level of visits. They began with an attempt to collect data via a survey from all specialties as described in the 2017 final rule. Given the low rate of response from practitioners, we shifted the study and focused on three high-volume procedures with global periods that were common enough to likely result in a robust sample size: (1) cataract surgery; (2) hip arthroplasty; and (3) complex wound repair.

A total of 725 physicians billing frequently for cataract surgery, hip arthroplasty, and complex wound repair reported on the time, activities, and staff involved in 3,469 visits. Our findings on physician time and work from the survey were broadly similar to what we expected based on the Time File for cataract surgery and hip replacement and somewhat different for complex wound repair.

(For the complete report, click here).

The third report in the series looks at ways we could consider revaluing procedures using the collected data. To provide us with estimates to frame a discussion, RAND modeled how valuation for procedures would change by adjusting work RVUs, physician time, and direct PE inputs based on the difference between the number of post-operative visits observed via claims-based reporting and the expected number of post-operative visits used during valuation. RAND looked at three types of changes: ( 1) Updated work RVUs based on the observed number of post-operative visits measured four ways (median, 75th percentile, mean, and modal observed visits); (2)Allocated PE RVUs reflecting direct PE inputs updated to reflect the median number of reported post-operative visits; and (3) Modeled total RVUs reflecting (a) updated work RVUs, (b) updated physician time, and (c) updated direct PE inputs, and including allocated PE and malpractice RVUs. This report is designed to inform further conversations about how to revalue global procedures.

(For the complete report, click here).

We will give the public and stakeholders time to study the reports we are making available along with this rule and consider an appropriate approach to revaluing global surgical procedures. We also note that the Office of the Inspector General (OIG) has published a number of reports on this topic. We will continue to study and consider alternative ways to address the values for these services.

Physician Supervision Requirements for Physician Assistants
Per CMS:

We are proposing to modify 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 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.

On a completely unrelated subject, CMS did not touch on MedPAC’s recent discussion regarding “incident to” billing for physician assistants. In case you missed it, TOA’s July 9, 2019, e-mail newsletter took a look at the issue.

Physical Therapy Services and New Modifiers
In exchange for removing Medicare’s therapy caps, the Bipartisan Budget Act of 2018 created a threshold of $3,000 in annual threshold for physical therapy services that will require Medicare to look at a beneficiary’s services. Once that threshold is reached, CMS will require the KX modifier to be added to therapy service codes to “confirm that the services are medically necessary as justified by appropriate documentation in the patient’s medical record,” CMS said.

Congress also reduced future Medicare payments for physical therapy assistants as a part of the 2018 budget deal.

CMS’s proposal would create a complex system for services furnished by a physical therapist assistant. The system would focus on a payment differential based on how many minutes of service are provided by a physical therapy assistant (beginning in 2022). The discussion can be found on page 249, and it includes numerous examples.

In the CY 2019 PFS final rule, in accordance with amendments to the Medicare law, we 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.  We also established that the statutory reduced payment rate for therapy assistant services, effective beginning for services furnished in CY 2022, does not apply to services furnished by critical access hospitals because they are not paid for therapy services at PFS rates.

Beginning January 1, 2020, these modifiers are required by statute to be reported on claims.  We are proposing a policy to implement the modifiers 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.

Advanced Imaging: Clinical Decision Support Requirements
Clinical decision support requirements for advanced imaging remain scheduled to go into effect on January 1, 2020, which will be an educational period (without penalties).

Stark Advisory Opinion Process
Per CMS:

CMS issues written advisory opinions on a case-by-case basis about whether a physician referral for certain health services is prohibited under Section 1877 of the Social Security Act (the “Stark Law”). Last year, CMS issued a Request for Information (RFI) to gather public input on how to address unnecessary burden created by the physician self-referral law, focusing in part on how it may impede care coordination, a key aspect of value-based healthcare. In response to the RFI, many health systems and provider groups urged CMS to update the regulations governing its advisory opinion process on physician referrals to reduce provider burden and uncertainty around compliance with the Stark Law. Therefore, CMS is soliciting comment on potential changes to its advisory opinion process to address these stakeholder comments. Other comments in response to the RFI are expected to be addressed in separate rule making.

MIPS Value Pathways
The PFS proposal also includes the policy proposal for Medicare’s quality payment system. The proposal would create the MIPS Value Pathways, which would reduce reporting requirements in CY 2021. The new proposal would focus on a smaller set of measures that are specialty-specific and more closely aligned with alternative payment models.

The payment proposal includes a request for information for the proposed new MIPS Value Pathways.

CMS’s summary of its major proposals for MIPS can be found on page 712.

The following is CMS’s example of a possible MIPS Value Pathway:

MIPS Quality & Cost Performance
The proposal would create the following values for the MIPS quality and cost performance measures:

    • The weight of MIPS’ cost performance category would be increased to 20% in 2020, 25% in 2021, and 30% in 2022.
    • The weight of MIPS’ quality performance category would be decreased to 40% in 2020, 35% in 2021, and 30% in 2022.

The proposed performance threshold for 2020 is 45 MIPS total points.

In addition, the MIPS Quality reporting threshold is proposed to increase from 60 percent of eligible cases per measure to 70 percent of eligible cases.

MIPS: Proposed Quality Measures
The proposed quality measures can be found on page 1345. Some include:

    • Multimodal pain management (measure steward: American Society of Anesthesiologists). Percentage of patients, aged 18 years and older, undergoing select surgical procedures that were managed with multimodal pain medicine.
    • Functional status change for patients with neck impairments (measure steward: Focus on Therapeutic Outcomes, Inc.). This is a PROM consisting of PROM of risk-adjusted change in functional status for patients 14 + with neck impairments.
    • The American Society of Anesthesiologists and CMS are proposing six additional measures, which can be found on page 1358.
    • Almost 50 measures in the orthopaedic-related set are either being proposed for additional or removal under this proposal. Some are related to PROMs.
    • A number of measures have been proposed for physical therapy, and they can be found on page 1523.

MIPS: Prescription Monitoring Program
Per CMS (page 844):

Given the stakeholder concerns discussed above regarding the lack of integration, the recent enactment of the SUPPORT Act (in particular, its provisions specific to Medicaid providers and qualified PDMPs), and the activities funded by the CDC, we believe that additional time is needed to evaluate the changing PDMP landscape prior to requiring a Query of PDMP measure, or introducing requirements related to EHR-PDMP integration.

Therefore, we are proposing to make the Query of PDMP measure optional and eligible for 5 bonus points for the Electronic Prescribing objective in CY 2020.

MIPS: Promoting Interoperability & Opioid Prescriptions
Per CMS on page 869:

We are seeking comment on the following three NQF measures for possible inclusion in the Promoting Interoperability performance category and any modifications that may be necessary to maximize their use in the Promoting Interoperability performance category:

      • Use of Opioids at High Dosage in Persons Without Cancer (NQF #2940).
      • Use of Opioids from Multiple Providers in Persons Without Cancer (NQF #2950).
      • Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer (NQF #2951).

We believe these measures relate to activities that hold promise in combating the opioid epidemic and can be supported using CEHRT to complete the actions of the measures.

MIPS: Advanced Payment Models
CMS begins its commentary on page 892. Per CMS:

Based on the MIPS APM criteria, we expect that the following 10 APMs will satisfy the requirements to be MIPS APMs for the 2020 MIPS performance period:

      • Comprehensive ESRD Care Model (all Tracks).
      • Comprehensive Primary Care Plus Model (all Tracks).
      • Next Generation ACO Model.
      • Oncology Care Model (all Tracks).
      • Medicare Shared Savings Program (all Tracks).
      • Medicare ACO Track 1+ Model.
      • Bundled Payments for Care Improvement Advanced.
      • Maryland Total Cost of Care Model (Maryland Primary Care Program).
      • Vermont All-Payer ACO Model (Vermont Medicare ACO Initiative).
      • Primary Care First (All Tracks).

Public Reporting of MIPS Data on Physician Compare
Per CMS (page 1014):

We are proposing to publicly report on Physician Compare: (1) aggregate MIPS data, including the minimum and maximum MIPS performance category and final scores earned by MIPS eligible clinicians, beginning with Year 2 (CY 2018 data, available starting in late CY 2019), as technically feasible; and (2) an indicator on the profile page or in the downloadable database that displays if a MIPS eligible clinicians is scored using facility-based measurement, as specified under § 414.1380(e)(6)(vi), as technically feasible.

Section 1848(q)(9)(A) and (D) of the Act requires that we publicly report on Physician Compare in an easily understandable format:

      • The final score for each MIPS eligible clinician;
      • Performance of each MIPS eligible clinician for each performance category;
      • Periodic aggregate information on the MIPS, including the range of final scores for all MIPS eligible clinicians and the range of performance of all the MIPS eligible clinicians for each performance category;
      • The names of eligible clinicians in advanced APMs and, to the extent feasible, the names of such advanced APMs and the performance of such APMs.

Section 1848(q)(9)(B) of the Act requires that the information made available under section 1848(q)(9) of the Act must indicate, where appropriate, that publicized information may not be representative of the eligible clinician’s entire patient population, the variety of services furnished by the eligible clinician, or the health conditions of individuals treated.

MIPS: Advanced Payment Model (APM) Incentive
Medicare’s commentary on the APM incentive can be found on page 1023.

Medicare Telehealth & Opioid Use Disorder
The public did not nominate any potential additions to Medicare’s telehealth list for CY 2020. However, CMS is proposing to add several face-to-face portions for opioid use disorder services.

Per CMS:

We did not receive any requests from the public for additions to the Medicare Telehealth

list for CY 2020. We believe that the vast majority of services under the PFS that can be appropriately furnished as Medicare telehealth services have already been added to the list.

However, there are three HCPCS G-codes describing new services being proposed in section II.H. of this rule for CY 2020 which we believe are sufficiently similar to services currently on the telehealth list to be added on a Category 1 basis.

Documentation Relief
The proposal would allow the physician, physician assistant, or advanced practice nurse to review and verify, as opposed to re-documenting information that is included in the record by physicians and other members of the medical team. This can be found on page 214.

Per CMS:

After considering the concerns expressed by these stakeholders, we believe it would be appropriate to provide broad flexibility to the physicians, PAs and APRNs (regardless of whether they are acting in a teaching capacity) who document and who are paid under the PFS for their professional services. Therefore, we propose to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. This principle would apply across the spectrum of all Medicare-covered services paid under the PFS. Because this proposal is intended to apply broadly, we propose to amend regulations for teaching physicians, physicians, PAs, and APRNs to add this new flexibility for medical record documentation requirements for professional services furnished by physicians, PAs and APRNs in all settings. We invite comments on this proposal.

ASCs and CRNAs: State Scope of Practice Requirements
The proposal would update the ASC conditions for coverage (CfC) to allow a CRNA or physician to examine and evaluate a patient in an ASC prior to a surgery. However, this would be based on a state’s scope of practice law.

Per CMS (page 687):

We are proposing to revise § 416.42(a), Surgical services, to allow either a physician or an anesthetist, as defined at § 410.69(b), to examine the patient immediately before surgery to evaluate the risk of anesthesia and the risk of the procedure to be performed. By amending the CfCs to allow an anesthetist or a physician to examine and evaluate the patient before surgery for anesthesia risk and the planned procedure risk, we would be making ASC patient evaluations more consistent by allowing the option for the same clinician to complete both pre- and post-procedure anesthesia evaluations.

This proposed change is a continuation of our efforts to reduce regulatory burden. This change would increase supplier flexibility and reduce burden, while allowing qualified clinicians to focus on providing high-quality healthcare to their patients. We are also requesting comments and suggestions for other ASC requirements that could be revised to allow greater flexibility in the use of NPPs, and reduce burden while maintaining high quality health care.

New Nervous System Codes for Pain Procedures
Under the proposal, new codes would be created for genicular nerve procedures and the SI joint RFA and other issues related to somatic nerve injections. However, CMS is also proposing to make RVU changes for the somatic nerve injections.

New CPT Codes Proposed for Dry Needling
The proposal would add two new CPT codes related to dry needling of musculature trigger points for CY 2020. (205X1, need insertion without injection, 1 or 2 muscles and 205X2, needle insertion without injection, 3 or more muscles.)

Potentially Mis-Valued RVUs
CMS provided a list of RVUs for new, revised, and potentially mis-valued codes on page 424.

Open Payments Program
Per CMS:

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 reduce the associated burden of reporting under Open Payments while also clarifying and making the data more useful to the public through minor reporting changes to the program. 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.