Breaking: 2020 fee schedule confirms E/M overhaul, updated rates, new codes and more

by DecisionHealth Staff on Nov 1, 2019
The vast reshaping of E/M documentation standards and payment changes took a significant step closer to reality as CMS put a stamp of approval on its previous proposals to overhaul how medical practices report office and outpatient E/M services in 2021.
Next year many providers will see a modest boost to the conversion factor that, along with relative value units (RVUs), dictates pay rates across all services in the Medicare physician fee schedule. The conversion factor will rise to 36.0896 in 2020, which CMS previously proposed, from 36.0391 in 2019, according to the final fee schedule. However, the anesthesia conversion factor will decrease to 22.2016 in 2020 from 22.2730 this year. That’s a drop from the proposed anesthesia conversion factor of 22.2774.
These are just some fast facts from Medicare’s 2020 final physician fee schedule that was released this afternoon. Here is our Friday-evening overview of changes that will impact your practice next year, and the year after. Subscribers can check back next week for more details and analysis.
CMS confirms 2021 E/M direction
Overall, the transformation of E/M reporting – involving E/M office codes 99202-99215, which account for 20% of annual Part B expenditures – looks similar to what proposed in July. Practices can opt to base their code level selections on medical decision-making (MDM) or time, rather than the additional elements of history and exam. CMS will defer to the MDM and time guidelines that the AMA released earlier this year.
In a potentially massive cost rebalance, CMS also finalized the relative value units (RVU) for the group of oft-used E/M services, which will determine 2021 pay rates. The RVU changes, for example, would boost payments for code 99214 – the most-reported E/M code – from $109 to $136 per claim, a 25% increase. Rates for 99213 would jump nearly 30%.
How CMS plans to square the large payment increases for the E/M services with necessary cuts to other services remains to be seen. However, the agency says it understands concerns regarding potential pay cuts to other fee-schedule services.
“Many commenters expressed concerns about the redistributive impact of revaluing of the office/outpatient E/M visit code set, particularly for practitioners who do not routinely bill office/outpatient E/M visits,” the agency states in the final rule. Some commenters suggested phasing in the E/M increases over a span of four or five years while other sought Congressional intervention to avoid cuts.
Yet no action is currently on the table. “Given that these revised codes and values do not take effect until CY 2021, and we do not know the magnitude of redistribution resulting from other policies we may adopt through rulemaking before then, we believe it would be premature to finalize a strategy in this final rule,” CMS states.
Editor's note: Share your thoughts on the 2021 E/M documentation and payment outlook by taking a brief, seven-question survey. Link here:
Care management, new codes and more
  • CMS introduces PCM for CCM. You’ll be able to get credit – and payment – if you provide chronic care management (CCM) to patients with one chronic condition next year. Medicare discussed the new service in the proposed physician fee schedule and unveiled the final codes today. You will report code G2064 for 30 minutes of work by a doctor or other qualified health care professional: “Comprehensive care management services for a single high-risk disease, e.g., principal care management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting at least three months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.” When clinical staff perform the work, you will report G2065.
  • Additional CCM changes on hold. Don’t worry about the substitute G codes for CCM and complex CCM that CMS floated in the proposed rule. At least not until 2021 or later. CMS backed off its plans, which would have included time refinements for CCM and descriptor tweaks for complex CCM, in part because the AMA/CPT editorial panel is working on these changes.
  • Online digital evaluations are still on, but watch the G-codes. Medicare is sticking to its plan to cover the new time-based online E/M and evaluation codes next year, but be careful if your clinical staff mix includes physicians, qualified health professionals such as nurse practitioners and clinicians who cannot independently report E/M services such as physical therapists. When you bill Medicare for their online evaluation services you’ll need to report a G code. For example, G2061 (Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes).
  • Potentially misvalued codes. CMS will evaluate the value of two potentially misvalued codes for CY 2020: 3D-rendering radiology add-on code 76377 and external counterpulsation therapy code G0166. A review last year of code G0166 did not take into account the total practice resources required to deliver the service according to an unnamed nominator, so CMS has agreed to re-evaluate it. CMS itself decided to examine the value of code 76377 after a 2018 review by the AMA Relative Value Update Committee (RUC) of a similar add-on code, 76376. The agency opted not to review two fine needle aspiration codes (10005 and 10021) as initially proposed, stating “we do not believe we have received any additional information to consider in the context of our previous review of these services.”
  • Telehealth opioid treatment codes added. CMS is finalizing the addition of three new telehealth codes for opioid treatment as part of its new bundled care program for treatment of opioid use disorders: G2086 (Office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month); G2087 (Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month); and G2088 (Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes). CMS will offer these services without the usual geographical limitations for telehealth. CMS also slightly increased the Medicare telehealth originating site fee to $26.65 in 2020, from $26.15 in 2019.
  • CMS flexes medical record documentation. In an effort to reduce “note bloat” and cut back on administrative time, the agency will allow physicians, physician assistants and advanced practice registered nurses (APRN) to review and verify – through a simple “sign and date” process – rather than re-document notes made in the medical record by other physicians, residents, medical, physician assistant, and APRN students, nurses, or other members of the medical team. CMS also defined the APRN group of providers, which includes nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists.
  • Primary care add-on codes. CMS also confirmed it will move ahead with one add-on E/M code in 2021 to pad provider payments. CMS is using an invalid placeholder code until it releases the final code this time next year: GPC1X (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient's single, serious, or complex chronic condition).
  • Shifting prolonged service codes. You can strike prolonged services without face-to-face contact codes 99358-99359 from your Medicare reporting in 2021, when CMS said it will no longer pay for the services. Instead, it will pay for the to-be-determined prolonged service code that the AMA is preparing for 2021.
Assess 2020 QPP updates
You won’t find many surprises about the Quality Payment Program (QPP) in the final rule but several divergences from what the agency proposed in July. CMS held back on a controversial plan to raise the cost category share of the Merit-based Incentive Payment System (MIPS) score to 20%, leaving it at 15% for 2020 “in light of concerns noted regarding more detailed and actionable performance feedback.”
Note that quality remains at 45% of your score, Promoting Interoperability at 25% and Improvement Activities at 15%. Also, the barrier to meet the exceptional performance threshold will be 85 points in 2020 rather than the proposed 80.
The MIPS Value Pathways (MVP) rethink of the MIPS program, with which CMS hopes to "remove barriers” to alternate payment models (APM) participation with "global or population quality measures calculated from claims-based quality data and promoting interoperability concepts," is approved for 2021 on the terms of the proposed rule.
While the program is still being worked out, and CMS will take input from stakeholders on its development throughout the upcoming year, the agency said it will use an "aligned set of measures" that is meant to reduce the number of measures clinicians need to report as well to as break down "silos" between specialties and provider types.
CMS also finalized the more difficult standards for Qualified Clinical Data Registries (QCDRs) from the proposed rule, including greater clinical input on measures, which is expected to drive many QCDRs out of business.
Physician assistants gain leeway
CMS' proposal for a major adjustment to the authority of physician assistants (PA) – allowing them to practice without specific assignment to an M.D., requiring only “documentation in the medical record of the PA’s approach to working with physicians" – is finalized. After a heavy round of comments, CMS did add some caveats. For example, it will require that in states where the PA’s scope of practice is not specified, the PA’s "working relationship" with the practice's physicians must be documented "at the practice level."
CMS cautiously approved its proposal to allow certified registered nurse anesthetists (CRNAs) to do pre-anesthesia assessments on patients as well as post-anesthesia assessments without the supervision of an M.D. The agency clarifies that "a physician must examine the patient to evaluate the risk of the procedure to be performed," while either "a physician or anesthetist must examine the patient to evaluate the risk of anesthesia."
But a proposal that PAs can serve as attending physicians for patients in Medicare hospice, with prescribing authority, is finalized as is.
Additional news and notes
  • Therapy modifiers report therapy assistant (PTA) involvement. CMS is finalizing plans to require therapy practices to append two new modifiers when therapy assistants perform more than 10% of the services. Beginning Jan. 1, 2020, physical therapy practices will report modifier CQ (Outpatient physical therapy services furnished in whole or in part by a physical therapy assistant) for the involvement of PTAs, while occupational therapists will append CO (Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant) for OTA involvement, according to the proposed physician fee schedule. In addition, CMS issued examples and specific scenarios for how the therapy practices can apply the 10% de minimus standard to know when to apply the modifiers. Beginning in 2022, Medicare will begin to apply a statutorily required payment reduction for services with the CO and CQ modifiers.
  • Therapy threshold, KX modifier use now codified. Though Medicare has already implemented the therapy threshold this year, CMS said it would add a new paragraph to the Medicare regulation to clarify the rules for the policy. In effect: In addition, therapists must append modifier KX for cases when a patient’s annual therapy cost has exceeded Medicare’s $3,000 annual threshold or the claims will be denied, CMS states. “By using the KX modifier on the claim, the therapy supplier or provider is attesting that the services are medically necessary and that supportive justification is documented in the medical record,” the agency states. CMS imposes a single $3,000 threshold for physical therapy and speech-language pathology services and a separate $3,000 threshold for occupational therapy. CMS says it will select its medical review targets based on certain criteria, such as practices with “a high percentage of patients receiving therapy beyond the medical review threshold as compared to peers.” The new threshold is required by the BBA of 2018.
  • Implantable glucose monitors. Category III codes 0446T-0448T, which describe implantation, removal and removal with reinsertion of implantable interstitial glucose sensors, are currently carrier priced, CMS notes, but that system is causing “significant confusion in the community” about Medicare payment for the systems, which has inhibited access. CMS is seeking comment by Feb. 20, 2020, on potential work RVUs and practice expense inputs to help the agency set national payment rates for the codes in 2021 rulemaking.
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