United States: CMS Finalizes Medicare Physician Fee Schedule Rates And Policies For CY 2020

The Centers for Medicare & Medicaid Services (CMS) has published its final Medicare physician fee schedule (PFS) rule for calendar year (CY) 2020. In addition to updating rates for physician services, the final rule revises numerous other Medicare Part B policies. Highlights of the final rule include the following:

• The final 2020 conversion factor is $36.0896, up slightly from $36.0391 in 2019 (and the same as in the proposed rule). The final rule also updates work and practice expense (PE) relative value units (RVUs) for numerous new, revised, and potentially misvalued codes, and it revises various direct PE inputs based on submitted invoices.
• CMS updated evaluation and management (E/M) visit coding and payment policies for 2021 to align with CPT Editorial Panel changes. These coding and payment policies are favored by some physician specialties and are controversial among others. While CMS anticipates that specialties that bill higher level established patient visits will see significant RVU increases, those physician specialties that do not generally bill office/outpatient E/M visits could see large payment decreases (because of budget neutrality rules). Future coding and valuation policies in the CY 2021 final rule could impact actual RVUs changes.
• CMS replaced the current Medicare requirement for the general physician supervision of physician assistants (PAs), including the immediate availability of the supervising physician to the PA for consultation, with medical direction and appropriate supervision as provided by state law. In the final rule, CMS clarified its proposed policy with regard to states with no explicit state law or scope of practice rules regarding physician supervision of PA services. Specifically, in such states, CMS defined physician supervision as a process in which a PA has a working relationship with one or more physicians to supervise the delivery of their health care services. Such physician supervision is evidenced by documenting at the practice level the physician assistant's scope of practice and the working relationships the physician assistant has with the supervising physician(s) when furnishing professional services.
• CMS streamlined documentation requirements for such physician supervision by allowing the physician, PA, or advanced practice registered nurse who furnishes and bills for his or her professional services to review and verify — rather than fully re-document — information included in the medical record by physicians, residents, nurses, medical, PA, and advanced practice registered nurse students, or other members of the medical team.
• CMS continued to implement a statutory requirement that modifiers be reported to identify certain therapy services that are furnished in whole or in part by physical therapy (PT) and occupational therapy assistants (OTA), beginning January 1, 2020. In the preamble, CMS noted that it received almost 9,000 public comments on this issue, and CMS modified a number of its proposed policies in response to these comments. With regard to the de minimis standard under which a service is considered to be furnished in whole or in part by a PTA or OTA when more than 10% of the service is furnished by the PTA or OTA, the final rule provides that only the minutes that the PTA/OTA spends independent of the therapist will count towards the de minimis Furthermore, based on comments, CMS will not require the treatment note to include an explanation of the application or non-application of the therapy assistant modifier for each therapy service furnished. CMS also dropped a proposed requirement that the therapist and therapy assistant minutes be included in the documentation. CMS committed to providing additional guidance regarding this policy.
• CMS adopted a number of changes to Open Payments reporting requirements, including: expansion of the definition of a covered recipient to include PAs, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives; the addition of Debt Forgiveness, Long-Term Medical Supply or Device Loan, and Acquisitions to the "nature of payment" categories; consolidation of medical education program categories; and standardization of data reporting requirements for drugs, devices, biologicals, and medical supplies.
• CMS made a series of changes to the physician self-referral (Stark Law) advisory opinion process. For instance, the rule: established a 60 business-day timeframe for issuing an advisory opinion; provided that an advisory opinion is binding on the Secretary and precludes the imposition of sanctions under the Stark Act on the parties requesting the opinion and any individuals or entities that are parties to the arrangement; specified CMS's right to rescind an advisory opinion; and clarified that individuals and entities may rely on an advisory opinion as non-binding guidance that illustrates the application of the physician self-referral law and regulations to the specific facts and circumstances described in the advisory opinion.
• The final rule contained no rulemaking or commentary from CMS regarding the pending requirements for consultation of appropriate use criteria (AUC) using clinical decision support (CDS) mechanisms by physicians ordering advanced diagnostic imaging services for Medicare outpatients. Consequently, CMS left intact the timeline of its requirements for such consultation when physicians order CT, MRI, PET or nuclear medicine studies. Next year, 2020, remains an "education and testing" year when such orders can be made without penalty even in the absence of an AUC consultation. Beginning 2021, however, AUC consultation will be mandatory.
• Among many other topics, the rule also addressed: establishment of a new Medicare Part B benefit for opioid use disorder treatment services (including medications for medication-assisted treatment) furnished by opioid treatment programs; beneficiary consent for communication technology-based services; ambulance cost data collection; Quality Payment Program and Medicare Shared Savings Program quality reporting requirements; and payment for chronic care, transitional care, and principal care management services.

This article is presented for informational purposes only and is not intended to constitute legal advice.