The Times They are A' Changing

By LUCY CARTER, CPA


The Times They are A' Changing  | CMS, Centers for Medicare & Medicaid Services, 2020 Physician Fee Schedule, PFS, Reimbursement, Medical Coding, RVUs, Lucy Carter, KraftCPAs.

Lucy Carter, CPA

Proposed 2020 Physician Fee Schedule

On July 29, 2019, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule for the physician fee schedule (PFS) that includes provisions to update payment policies, rates, and quality provisions beginning on or after Jan. 1, 2020.

The 2020 proposed rule (along with other proposed rules) represents a broader strategy designed to "create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation."

How will these new strategies impact providers in 2020?

Rate Setting & Conversion Factor

Multiple changes are proposed to the practice expense component of the Relative Value Unit (RVU). Additionally, refinements to update premium data for malpractice expense and geographic practice indices are proposed (GPCIs).

Practice expense RVU proposed changes include:

  • Several new equipment codes
  • Corrections to indirect physician expense allocations

In addition to the above refinements based on premium data, changes to the malpractice RVUs include seeking feedback on specialty mix assignments for low volume services.

Geographic Practice Cost Indices (GPCIs) proposed changes include:

  • Weight by total employment when computing county median wages for each occupation code
  • Use a weighted average when calculating the final county-level wage index

The revisions to the components above, along with the budget neutrality requirement, result in an adjustment to increase the conversion factor from $36.04 to $36.09.

The projected impact of these changes, based on specialty, are minimal. Many specialties will experience no change (i.e. family practice). The maximum projected increase is 3 percent for clinical psychologists and social workers and the largest projected decrease is 4 percent for ophthalmology.

Medicare Telehealth Services

For 2020, the following codes are proposed to address telehealth services for the treatment of opioid use: GYYY1, GYYY2, and GYYY3.

E-visits

The proposed rule includes a work RVU of .25 for 98X00, and .44 for 98X01 and 98X02.

Evaluation and Management Services (E/M)

In 2020, CMS proposes to abandon many of the policies finalized for the 2019 year. The most significant change proposed relates to the 2019 change collapsing office/outpatient level 2, 3, and 5 E/M services. Instead, CMS proposes to largely follow recommendations from an AMA CPT workgroup on E/M (for 2021 implementation).

Key proposed changes include:

  • Delete Level 1 for new patients (retain Level 1 for established patients).
  • Pay separate rates for five levels of established visit codes and four levels of new patient visit codes.
  • Revise the times and medical decision-making process for all codes.
  • Utilize a single add-on code (99XXX) for prolonged office/outpatient E/M visits.
  • Require the performance of a history and exam only as medically appropriate.
  • Consolidate add-on codes GPC1X and GCG0X so that only the former remains in effect, related to ongoing care for a complex chronic condition.

Proposed changes to E/M payment and coding policies, if implemented in 2021, will generate an estimated 16 percent increase for endocrinology, 15 percent increase for rheumatology and 12 percent increase for hematology/oncology and family practice. Ophthalmology is estimated to experience an estimated 10 percent decrease followed by radiology, physical/occupational therapy, pathology and cardiac surgery with estimated 8 percent declines.

Therapy Services

In the 2019 PFS final rule, CMS established modifiers to identify therapy services that are furnished in whole or part by physical therapy (PT) and occupational therapy (OT) assistants. A de minimis 10 percent standard was set for when these modifiers would apply to specific services.

Beginning in 2020, the modifiers are required to be reported on claims (the 10 percent de minimis standard will continue to be applied).

Physician Supervision Requirements for PAs

CMS proposes to modify the regulations on physician supervision of physician assistants to give PAs greater flexibility to practice more broadly in the current healthcare system. Changes in flexibility will be governed by state law and state scope of practice.

Principal Care Management (PCM) Services

CMS proposes to introduce new coding for PCM services which would pay clinicians for providing care management for patients with a single serious and high-risk condition. A qualifying condition would be expected to last between three months and one year, or until the death of a patient. The condition may have led to a recent hospitalization, and/or place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

Proposed MSSP Quality Measure Changes for 2020 Performance Year

CMS is soliciting comments 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. CMS believes that aligning quality metrics across programs will allow ACOs to more effectively target their resources toward improving care.

Summary

The comment period for the proposed rule closed Sept. 27, 2019. Now we wait. While we wait for the final rule, reviewing the impact of the proposed changes on specific specialties is encouraged. The proposed rule is published in the Federal Register, Vol. 84, No. 157/ Wednesday, August 14, 2019/Proposed Rules (link available in the online version of this article at NashvilleMedicalNews.com). CMS has also published a fact sheet which is published on their website at cms.gov/newsroom.


Lucy Carter, CPA, is a member (owner) in KraftCPAs PLLC and practice leader of the firm's healthcare industry team. Contact her via email at lcarter@kraftcpas.com. For more information, visit www.kraftcpas.com/healthcare.htm.

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