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  • Washington Highlights

    CMS Issues Proposed Medicare Physician Fee Schedule and Quality Payment Program Rule

    Gayle Lee, Director, Physician Payment & Quality
    Kate Ogden, Physician Payment & Quality Specialist

    The Centers for Medicare and Medicaid Services (CMS) July 29 released the calendar year (CY) 2020 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) proposed rule.

    This rule updates payment rates and policies for services provided by physicians and other clinicians to Medicare beneficiaries in 2020. The rule also proposes changes to the QPP, which consists of two participation pathways: the Merit-based Incentive Payment System (MIPS) that measures performances based on four categories, and advanced alternative payment models (APM).


    In the MPFS section of the rule, CMS proposed a 2020 conversion factor of $36.09, a slight increase from the CY 2019 conversion factor of $36.04. CMS also proposed modifying the documentation policy so that physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives could review and verify, rather than redocument, 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 new Current Procedural Terminology (CPT) codes on interprofessional internet consultations (99451-99452), CMS is seeking comment on whether a single advance beneficiary consent could be obtained for multiple communication-based technology services, the appropriate interval of time or number of services for which consent could be obtained, and any program integrity concerns associated with these potential changes.

    CMS also proposed the following significant changes to evaluation and management (E/M) payment policies that would be effective Jan. 1, 2021, to align with changes established by the CPT Editorial Panel for office/outpatient E/M visits:

    • Retain five levels of coding under E/M for established patients and reduce the number of levels to four 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, previously finalized in 2019;
    • Increase payment for office/outpatient E/M visit based on the American Medical Association’s (AMA) RVS Update Committee (RUC) 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 two through five 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; and
    • 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.


    In the QPP section of the rule, CMS proposed a new MIPS framework called the MIPS Value Pathways (MVPs). The MVPs create tracks or bundles of care to move towards more aligned measure sets across performance categories based on clinician services. CMS also proposed changes to the Cost and Quality performance categories over the next three years as follows:

    • For 2020 performance period: Quality decreased from 45% in 2019 to 40%; Cost increased from 15% in 2019 to 20%
    • For 2021 performance period: Quality 35%; Cost 25%
    • For 2022 performance period: Quality 30%; Cost 30%

    CMS proposed additional changes to the Cost performance category, proposing 10 new episode-based cost measures and revisions to Medicare Spending Per Beneficiary and Total Per Capita Cost. CMS also proposed an increase in the MIPS performance threshold over the next two performance years:

    • 2020 performance period: 45 points, increased 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 also proposed increasing the participation threshold for the Improvement Activities performance category to 50% of clinicians in a practice, from a single clinician in 2019. Lastly, CMS proposed to modify the APM Scoring Standard to allow APM entities and MIPS-eligible clinicians participating in APMs to report on MIPS quality measures for the MIPS Quality performance category. APM entities would receive a score based on individual, tax identification number, or APM entity reporting.

    CMS issued fact sheets on the MPFS and the QPP proposed rule. The AAMC will analyze the proposal and its impact in the coming weeks and will be submitting comments by the Sept. 27 deadline.