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CMS Issues Final Physician Fee Schedule and Quality Payment Program Rule

November 8, 2019

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PRESS CONTACTS
Gayle Lee, Director, Physician Payment & Quality
Kate Ogden, MPH, Policy & Regulatory Analyst, Physician Payment & Quality

The Centers for Medicare and Medicaid (CMS) Nov. 1 released the calendar year (CY) 2020 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) final rule. The AAMC submitted comments on the proposed rule [see Washington Highlights, Sept. 27].

The rule finalizes significant changes to evaluation and management (E/M) coding, payment, and documentation policies. This rule will update payment rates and policies for services provided by physicians and other clinicians to Medicare beneficiaries in 2020. The rule also finalizes changes to the Quality Payment Program (QPP), which consists of two participation pathways — Merit-based Incentive Payment System (MIPS), which measures performance based on four categories, and advanced alternative payment models in which clinicians may earn incentive payments based on sufficient participation in models.

Medicare Physician Fee Schedule

In the MPFS section of the rule, CMS finalized a 2020 conversion factor of $36.09, a slight increase from the CY 2019 conversion factor of $36.04. CMS also finalized modifications to the documentation policy so that physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives could review and verify (sign and date) rather than redocumenting notes made in the medical record by other physicians, residents, nurses, students, and other members of the medical team, including notes documenting the practitioner’s presence and participation in the services.

For CPT codes that describe interprofessional internet consultations, (99451 and 99452, 99446-99449) and HCPCS codes G2010 and G2012, CMS changed its policy to permit a single advance beneficiary consent to be obtained at least annually for multiple communication-based technology services and interprofessional consultation services. In the past, CMS required that advance verbal consent be obtained for each service furnished to the beneficiary.

CMS also finalized significant changes to E/M payment policies that would be effective Jan. 1, 2021 to align with changes set forth by the CPT editorial panel for office/outpatient visits:

  • Levels to 4 for E/M visits for new patients (CPT code 99201 is deleted).
  • Make separate payment for the five levels of E/M rather than continuing with the blended rate.
  • Increase payment for office/outpatient E/M visit based on the American Medical Association (AMA) RVS Update Committee recommended values.
  • Adopt revised CPT code descriptors for CPT codes 99202-99215 that revise the times and medical decision-making process for all the codes and require performance of history and exam only as medically appropriate.
  • For levels 2 through 5 office/outpatient E/M visits, the code level reported would be decided based on either the level of medical decision making (as redefined in new AMA/CPT guidance) or the total time personally spent by the reporting practitioner on the day of the visit (including face-to-face and non-face-to-face time).
  • Payment for prolonged office/outpatient E/M visits using a revised CPT code for such services.
  • Consolidate the add-on code for office/outpatient E/M visits for primary care and nonprocedural specialty care that was finalized in the CY 2019 Physician Fee Schedule rule by creating a single code. This code describes 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.

Quality Payment Program

In the QPP section of the rule, CMS finalized the proposed new MIPS participation framework called MIPS Value Pathways (MVPs). The MVPs create tracks or bundles of care to move toward more aligned measure sets across performance categories based on clinician services or patient conditions.

CMS redacted proposed changes to the cost and quality performance categories for 2020, maintaining the cost weight at 15% and the quality weight at 45%, with no change from 2019. CMS also proposed changes to quality and cost weights for future years but ultimately decided not to finalize any changes and will be making proposals in next year’s rulemaking. Additionally, CMS finalized the data completeness threshold for the quality performance category to 70%.

CMS finalized the addition of 10 new episode-based cost measures and revisions to the Medicare Spending Per Beneficiary and Total Per Capita Cost for the cost performance category.

CMS also finalized an increase in the participation threshold for the Improvement Activities performance category to 50% of clinicians in a practice, from a single clinician in 2019.

Finally, CMS finalized as proposed an increase to the MIPS performance threshold over the next two performance years:

  • 2020 performance period: 45 points, from 30 points in 2019.
  • 2021 performance period: 60 points.
  • Exceptional performance threshold would increase to 80 points in 2020, and 85 points in 2021.

CMS released fact sheets on the Medicare Physician Fee Schedule final rule and the Quality Payment Program final rule.

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