CMS Proposes Medicare Physician Fee Schedule & Quality Payment Program Rule for CY 2020

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed rule updating Medicare policies and providing payments for services furnished under the Medicare Physician Fee Schedule (PFS) in CY 2020.

Medicare Physician Fee Schedule (MPFS) Proposals

  • Payment Changes to Office/Outpatient Evaluation and Management (E/M) Services
    • Reducing coding complexity by consolidating CPT coding from 5 levels to 4 levels for office/outpatient E/M visits for new patients
    • Improving payment for office/outpatient E/M visits, and establish a new add-on code for prolonged service time.
    • Consolidating the Medicare-specific add-on code in primary care and non-procedural care into a single code for ongoing care related to a single, serious, or complex condition
  • Medical Record Documentation
    • Modifying the documentation policy, allowing MDs, PAs, NPs, CNS, and certified nurse-midwives to review and verify notes in medical records made by other members of the medical team
  • Chronic Care Management (CCM) Services
    • Creating a new set of HCPCS G Codes for chronic care management (CCM) services that would allow clinicians to bill more specific to illness complexity. Unlike current CCM codes, the proposed G codes would allow clinicians to bill incrementally based on time and resources required to treat a patient with complex illness
    • Creating a new Principal Care Management (PCM) code for clinicians providing care management to patients with a single serious and high-risk condition
  • Stark Advisory Opinion Process
    • Seeking input on potential changes to advisory opinion process on physician referrals

 Quality Payment Program (QPP) CY 2020 Proposals

  • MIPS Scoring and Weights
    • Quality 40%; Cost 20%; Promoting Interoperability 25%; and Improvement Activities 15%
    • Performance threshold increased from 30 points to 45 points
    • Exceptional performance threshold increased from 75 points to 80 points
  • Quality Category
    • Increasing the data completeness criteria for all submission types
    • Modifying benchmarks for measures CMS believes could incentive inappropriate treatment for particular patients: MIPS #1 ((NQF 0059): Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%) and MIPS #236 (NQF 0018): Controlling High Blood Pressure
  • Improvement Activities Category
    • Adding 2 activities, modifying 7 existing activities, and removing 15 existing activities
    • Establishing factors to consider for removing activities
    • Requiring that at least 50% of ECs in a group or virtual group participate in/perform an improvement activity
  • Promoting Interoperability Category
    • CY 2019 – requiring a yes/no for Query of PDMP measure and redistributing points for Support Electronic Referral Loops by Sending Health Information measure to the Provide Patients Access to Their Health Information measure if exclusion applies
    • CY 2020 – removing opioid treatment agreement measure
  • Cost Category
    • Revising the total per capita cost (TPCC) and Medicare Spending Per Beneficiary-Clinician (MSPB-Clinician) measures
    • Proposing 10 new episode-based measures:
      • Acute Kidney Injury Requiring New Inpatient Dialysis
      • Elective Primary Hip Arthroplasty
      • Femoral or Inguinal Hernia Repair
      • Hemodialysis Access Creation
      • Inpatient Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
      • Lower Gastrointestinal Hemorrhage
      • Lumbar Spine Fusion for Degenerative Disease, 1-3 Levels
      • Lumpectomy Partial Mastectomy, Simple Mastectomy
      • Non-Emergent Coronary Artery Bypass Graft (CABG)
      • Renal or Ureteral Stone Surgical Treatment

The QPP proposals also included several proposals for CY 2021 that we will provide in the detailed summary.

For additional information, please see the following:

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