After eagerly awaiting for the release of the Medicare Physician Fee Schedule, the Centers for Medicare & Medicaid Services (CMS) finally released the proposed rule yesterday afternoon. Below is a quick summary.
CMS Proposes to Adopt AOA and Other Stakeholder Recommendations for E/M Visit
In a proposed rule released yesterday afternoon, CMS stated its intention to further revise payment changes for levels 2 through 4 Office/Outpatient Evaluation and Management (E/M) visits for new and established patients that were finalized last year and had been scheduled to take effect on January 1, 2021. Instead, CMS is now proposing to adopt revised CPT guidelines for E/M visits, and RUC-recommended values for CPT codes 99202-99215.
In the Medicare Physician Fee Schedule Final Rule for calendar year (CY) 2019, CMS adopted policy changes for services starting January 1, 2021, that would blend payment rates for levels 2 through 4 Office/Outpatient E/M visits for new and established patients, while maintaining separate payment rates for level 5 visits, and allow for document of services based on medical decision making (MDM) or time. To align the payment rates, documentation standards would have had to meet a level 2 criteria visit if using MDM, or if using time to select an E/M visit, documentation would have had to reflect the typical amount of face-to-face time spent with the patient, except for extended or prolonged visits exceeded by 15 minutes.
Now, under the new framework, CPT code 99201 would be deleted, payment rates for CPT codes 99202 - 99215 would remain separate, and documentation would be based on new guidelines for MDM or time. Use of history and/or physical exam to determine E/M code selection would be eliminated unless medically necessary and clinically appropriate.
As many physicians will attest to, E/M visits have been undervalued for many years. The AOA successfully advocated for the proposed payment changes through participation in revision of the E/M guidelines, and a RUC survey conducted by more than 50 specialty societies to revalue physician work, practice expense inputs and time.
CMS is also proposing to delete the new add-on code (GPRO1) finalized last year for Prolonged Office/Outpatient E/M visits, and establish a new code with a work RVU of 0.61 and 15 minutes of physician time. To simplify new add-on codes previously finalized for primary (GPC1X) and specialty (GCG0X) care, CMS proposes to consolidate both services into a single code by deleting GPC1X and revising the descriptor for GCG0X with a work RVU of 0.33 and 11 minutes of total time.
A side-by-side comparison of proposed RUC-recommended work RVUs and physician time for Office/Outpatient E/M visits and the new prolonged service visit is provided below:
To account for E/M visit RVU changes, the proposed conversion factor for CY 2020 will change from $36.04 to $36.09, a slight increase above the CY 2019 conversion factor.
Transitional Care Management and Care Coordination Services
In 2018, the AOA advocated for an increase in transitional care management (TCM) services. For CY 2020, CMS proposes to adopt the RUC-recommended work RVU of 2.36 for CPT code 99495 and the RUC-recommended work RVU of 3.10 for CPT code 99496. To further support care coordination for patients with multiple chronic conditions, CMS is proposing to create a set of Chronic Care Management (CCM) services to allow physicians to bill for additional time and resources required for certain complex cases.
Review and Verification of Medicare Record Documentation
CMS also proposes to establish general principles to allow physician assistants (PAs) and advance practice registered nurses (APRNs) authorized to bill for their professional services under Medicare Part B to review and verify, rather than re-document, information entered into in a patient’s medical record by physicians, residents, nurses, students or other members of a medical team. This change is consistent with the documentation changes implemented in the CY 2019 final rule for physicians.
Physician Supervision for Physician Assistant (PA) Services
To better align supervision requirements for PA services with other non-physician practitioners, CMS is proposing to allow PAs to practice more broadly according to state laws governing scope of practice where applicable.
Other provisions in the proposed rule include updates to the Quality Payment Program, and mandates for Medicare coverage of opioid treatment programs and the creation of a bundled episode of care for management and counseling for opioid use disorder.
The AOA will continue to review the proposed rule and provide a detailed analysis in the coming weeks. The proposed rule will be published in the Federal Register on August 14, 2019. Additional information on changes in the proposed rule will be forthcoming in August. Future communication will also include advocacy alerts and opportunities to communicate directly with CMS on how the rule may impact your ability to practice medicine.