On Aug. 15, 1935, Will Rogers died in a plane crash near Point Barrow, Alaska. He is an Oklahoma legend and one of the best political satirists and commentators ever. I often wonder what his commentary would be on the state of U.S. politics in 2019. As an aside, Oklahoma City has two airports named after people who died in that same plane crash. That seems odd to me.
On July 29, CMS released the 2020 Medicare physician fee schedule proposed rule. This proposal sets forth changes in payment values and quality/performance reporting requirements for family physicians participating in Medicare. The proposed rule also impacts the Quality Payment Program.
The AAFP has published a summary(4 page PDF) of the proposed fee schedule. You also may find value in CMS fact sheets on proposed changes to the fee schedule and the QPP. If you have questions or comments on the fee schedule to address to the AAFP.
Comments are due to CMS by Sept. 27. The AAFP will be submitting comprehensive comments on the proposed rule, along with several recommendations for improving it. Individual family physicians who are so inclined can submit comments to CMS electronically.
The final rule is excessive, to say the least. This post also is long as a result. Please note that I have pulled out some key items that AAFP staff members have identified as the most important recommended changes for family physicians.
Conversion Factor for 2020
CMS has proposed a conversion factor of $36.09 for 2020, which is 5 cents more than the 2019 conversion factor of $36.04. Please hold your applause.
Evaluation and Management
Under the proposed rule, there would be no change in total Medicare allowed charges for family medicine in 2020. However, total allowed charges for family medicine would increase 12% in 2021. For more analysis on changes in allowable charges for 2021, please see the two tables at the end of the AAFP summary.
CMS proposes to accept the recommended changes in values for the office/outpatient evaluation and management visit codes for 2021 as recommended by the AMA/Specialty Society Relative Value Scale Update Committee.
In addition, the agency proposes to consolidate the Medicare-specific add-on code for office/outpatient E/M visits for primary care and nonprocedural specialty care, which was finalized in 2019 for implementation in 2021, into a single code. This code would describe 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.
CMS also proposes to
- pay clinicians across all specialties for the time they spend managing patients with greater needs and multiple medical conditions, starting in 2020;
- increase payment for transitional care management and establish a set of Medicare-developed Healthcare Common Procedure Coding System G codes for certain chronic care management services; and
- create new coding for principal care management services, which would pay clinicians for providing care management for patients with a single, serious or high-risk condition.
The proposed rule would finalize and implement changes originally proposed in the 2019 fee schedule meant to simplify billing and coding requirements for office-based E/M services by aligning coding requirements with new guidance from the CPT Editorial Panel. These changes would apply to office/outpatient E/M visits beginning in 2021. To accomplish this, CMS proposes to
- retain five levels of coding for established patients,
- reduce the number of levels to four for office/outpatient E/M visits for new patients,
- revise the times and medical decision-making processes for all office-based E/M codes and require performance of history and exam only as medically appropriate, and
- allow clinicians to choose the E/M visit level based on either medical decision-making or time.
CMS did not include the RUC’s recommended changes to include increased E/M values in the global surgery codes.
For the improvement activities performance category, CMS proposes to
- remove certain accreditation criteria for patient-centered medical home practices,
- increase the participation threshold for group reporting to require at least 50% of clinicians in a practice to perform an activity to receive credit,
- update the improvement activity inventory and establish criteria for removal in the future, and
- modify the definition of a rural area.
Quality Payment Program
In 2015, the Medicare Access and CHIP Reauthorization Act was signed into law. Since that implementation, CMS has made annual revisions to the two payment pathways established by the law — the Merit-based Incentive Payment System and the Advanced Alternative Payment Model. For 2020, CMS is proposing several changes to both the MIPS and AAPM pathways, but the most substantive changes would impact MIPS. Those proposals would
- increase the minimum threshold to avoid negative payment adjustments to 45 points in 2020 and 60 in 2021, and increase the threshold for exceptional performance to 80 points in 2020 and 85 points in 2021;
- reduce the quality performance category weight to 40% in 2020, 35% in 2021, and 30% in 2022, and increase the cost performance category weight to 20% in 2020, 25% in 2021 and 30% in 2022; and
- add 10 new episode-based measures to the cost performance category and revise the current measures for Medicare spending per beneficiary and total per capita cost.
CMS also proposes a new way for physicians to participate in the MIPS pathway. The new program, called the MIPS Value Pathways, would begin in the 2021 performance period. The MVPs would allow clinicians to report many fewer quality measures than required under the current MIPS framework. The MVP measures would be specialty-specific, outcome-based and more closely aligned with APMs. In addition, CMS anticipates MVP participants would receive more timely feedback and performance data.
CMS did not propose significant changes to the promoting interoperability performance category, but the agency still is seeking comments on several areas. Among the categories in which CMS is seeking additional feedback, the AAFP will comment on CMS proposals to
- allow APM entities and MIPS-eligible clinicians participating in APMs the option to report on MIPS quality measures for the MIPS quality performance category,
- establish a MIPS APM quality reporting credit for APM participants in other MIPS APMs where quality scoring through the APM is not technically feasible, and
- apply the existing extreme and uncontrollable circumstances policies to MIPS-eligible clinicians participating in MIPS APMs who are subject to the APM scoring standard and would report on MIPS quality measures.
Opioid Treatment Programs
CMS proposes Medicare coverage to pay opioid treatment programs for delivering medication-assisted treatment to beneficiaries suffering from opioid use disorder. OTPs must be accredited by the Substance Abuse and Mental Health Services Administration.
CMS also proposes to make a new monthly bundled payment to clinicians for management and counseling involving MAT for patients with OUD. This bundled payment to clinicians would cover care activities such as overall patient management, care coordination, individual and group psychotherapy, and substance use counseling, a change that would increase patient access to evidence-based services that support OUD recovery.
I recognize that this is a substantial amount of information to sift through. The good news is you don’t have to worry about the full proposed rule because the AAFP will do that on your behalf, but many members will want to stay updated on the proposed changes in E/M codes and documentation requirements.
Also, I would draw your attention back to the exciting news that allowed payments to family physicians participating in the Medicare program would increase 12% in 2021 under the proposed rule.
We are pushing extremely hard to convince CMS to implement these changes in 2020 because the historical underfunding of primary care needs immediate attention — not a future promise.
For More Information: https://www.aafp.org/news/blogs/inthetrenches/entry/20190820itt-2020mpfs.html