Highlights: CMS releases 2020 Physician Fee Schedule proposed rule

Grant Huang, CPC, CPMA
Director of Content

You could see a major turnaround on E/M payments, along with tweaks to transitional and chronic care management services, more flexibility with physician supervision and documentation requirements, and new payments for patients with serious chronic conditions, all in the 2020 Medicare Physician Fee Schedule (PFS) proposed rule.

The PFS proposed rule also includes the usual annual revaluations of specific codes as well as provisions to implement a statutorily mandated new benefit for opioid abuse treatment as well as proposals to the Quality Payment Program (QPP) for 2020. The QPP portion of the PFS includes proposed changes to the Merit-based Incentive Payment System (MIPS) for the 2020 reporting year (the 2018 MIPS results were just released in July).

CMS released the 1,704-page PFS proposed rule on July 29, nearly three weeks later than it usually does, possibly because of the new opioid benefit as well as the consolidation of the QPP proposed rule into the PFS. For 2020, CMS is setting the proposed conversion factor at $36.09, up from the 2019 conversion factor of $36.04.

This article will provide bullet-point highlights of the major provisions in the PFS proposed rule, while upcoming issues will dig deeper into the most potentially impactful items. Below are the major highlights.

• Reversal on 2021 E/M payment changes. CMS now proposes to eliminate the blended payment rate for outpatient E/M code levels 2-4 that had been finalized in the 2019 PFS.
• Physician assistant supervision requirements. CMS wants to relax the supervision requirements for physician assistants (PAs), such that documentation in the medical record regarding the contribution of the PA would be sufficient (unless superseded by more restrictive state laws).
• Physician verification of medical record documentation. In a move that mirrors previous policy changes concerning medical student documentation, CMS proposes allowing physicians and non-physician practitioners (NPPs) to review and verify notes made in the record by other physicians, residents, nurses, students, or “other members of the medical team.” This would allow physicians and NPPs to simply sign and date such documentation rather than having to re-document it themselves.
• Transitional and chronic care management services. CMS wants to increase payment for transitional care management services and expand the code set for chronic care management services in 2020. The expanded code set would allow providers to bill incrementally for additional time spent on management of patients with multiple chronic conditions.
• New “Principal Care Management” service. This new service would reimburse providers who manage patients with a single, serious and high-risk condition, similar to the other care management services, but specifically targeting single-condition patients rather than those with multiple such conditions.
• New coverage for opioid use disorder treatment. This provision outlines how CMS would implement a new Part B benefit for opioid use disorder (OUD) treatment services, which it is obligated to create under a 2018 law enacted to address the national opioid abuse crisis.

Proposed changes to MIPS for 2020
CMS includes proposed tweaks to the MIPS program in 2020 as part of its PFS proposed rule. Many of these provisions are part of the phased approach to MIPS that CMS is obligated to take as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which created the MIPS program and set forth the broad outlines for its implementation. Below are the highlights.

• Minimum threshold of 45 points. For 2020, CMS proposes a minimum MIPS composite score of 45 points to avoid a negative payment adjustment in 2022. This threshold is 30 points for the 2019 performance year.
• Exceptional performance threshold of 80 points. On the flip side, CMS proposes setting the exceptional performance threshold at 80 points. Providers who reach or exceed this threshold are eligible for additional positive payment adjustments in 2022. Under MACRA, CMS must set the performance threshold at the mean or median of the final scores for all MIPS-participating providers for a prior period.
• Reweighting MIPS categories. CMS proposes reducing the Quality category of MIPS to a score weight of 40% in 2020, 35% in 2021, and 30% in 2020. The Cost category would be reweighted accordingly to 20% in 2020, 25% in 2021, and 30% in 2022 to offset the reductions in the Quality category. These changes are all in line with CMS goals at the beginning of the MIPS program.
• Removal of some measures, addition of others. As part of its ongoing management of the MIPS program, CMS proposes eliminating “low-bar, standard of care, process measures” and replacing them with high-priority quality measures as well as new, specialty-specific measure sets (for 2020, this would include speech language pathology, audiology, pulmonology, endocrinology, and more).

Source documents and comment period
You can find a PDF of the complete text of the 2020 PFS proposed rule here, and a CMS fact sheet for the QPP proposed rule (including all MIPS provisions) here. If you would like to comment on any of these proposals, the comment period for the PFS proposed rule begins on Aug. 14 and runs until Sept. 27, 2019. Comments may be submitted via Regulations.gov starting Aug. 14.

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