Arent Fox

The Centers for Medicare and Medicaid Services (CMS) recently released the CY 2020 Proposed Physician Fee Schedule.

The proposed Physician Fee Schedule (PFS) is published annually by CMS and contains, among other things, updated information on Medicare payment rates for current procedural terminology (CPT) codes, newly proposed CPT and HCPCS codes, and proposed billing requirement changes.

The proposed PFS is open to public comment for a period of 60 days, providing stakeholders with an opportunity to comment on the proposed changes. The final PFS typically is published in early November and becomes effective on January 1 of the following year.

Some of the notable elements of the proposed PFS include:

1. Updates to the evaluation and management (E/M) codes. The CY 2019 final PFS made changes to the payment rates for E/M visits, including implementing blended payment rates for established patient office visits coded as level 2 through level 4. Following issuance of the CY 2019 final PFS, CMS continued holding outreach sessions with physician stakeholders regarding the changes. During these sessions, the physician stakeholders expressed concerns that the blended payment rates may inappropriately incentivize multiple, shorter patient visits and lead to practitioners prioritizing treatment of less complex patients. The proposed changes were scheduled to go into effect on January 1, 2021.

In response to these concerns, CMS proposes to eliminate the blended rate methodology and revert to separate payment rates for all five levels of established patient office visit E/M codes. CMS also clarified that level 1 visits would only describe visits performed by clinical staff for established patients, and a visit would not be billed as a level 1 visit if treatment was rendered by a physician, physician assistant, nurse practitioner, or other independent practitioner.

Additional changes to E/M coding and reimbursement also include:

  • Eliminating code 99201, a problem-focused, straightforward visit, thereby reducing the number of visit levels available for coding a new patient visit to four;

  • Revising the applicable time and medical decision making processes for all codes, including requiring a complete history and physical only when medically appropriate, and adopting the coding, prefatory language, and interpretive guidance framework issued by the AMA/CPT; and

  • Proposing a new CPT code, 99XXX, to account for prolonged office or outpatient visits. This new code would replace code GPRO1, which is currently used to indicate an extended visit.

All proposed E/M coding changes would go into effect on January 1, 2021.

2. Proposed expansion of benefits to treat opioid dependence, including through the use of telehealth services. The 2018 SUPPORT Act established a new Part B benefit for services provided during treatment of opioid use disorders. These services included administration of medication through targeted treatment programs. The proposed PFS includes definitions of various treatment services included in the SUPPORT Act, and establishes reimbursement rates for the treatments. The rates vary by medication type, as well as the intensity of the services provided as part of the treatment.

In addition to the medication-assisted treatments, CMS also proposes to add new codes and reimbursement for bundled episodes of care for the management and counseling of opioid use disorders. These bundles would provide reimbursement on a monthly basis for care management and coordination, individual and group therapy, and substance use counseling; however they would not include reimbursement for medication therapies. The proposed codes for these services are:

  • GYYY1 (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);
  • GYYY2 (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
  • GYYY3 (an add-on code to be used where additional extraordinary services are provided in one month, typically during a very resource-intensive period of treatment, where the time spent on the service is in excess of 120 minutes per month).

CMS further proposed that the new G codes be available for treatment provided via telehealth because the services “are sufficiently similar to services currently on [Medicare’s] telehealth list.” The opioid use G codes are not subject to Medicare’s general telehealth restrictions. As a result, geographic limitations and originating site restrictions do not apply to these services—therefore telehealth services provided to a patient while the patient is at home are eligible for reimbursement.

3. Modifications to Open Payments / Sunshine Act reporting requirements. The SUPPORT Act expanded the Open Payments/Sunshine Act reporting requirements. The original Open Payments/Sunshine Act requires pharmaceutical and device manufacturers to report certain payments and transfers of value made to physicians and teaching hospitals. The SUPPORT Act expanded the Sunshine Act’s reporting obligations to include payments and transfers of value to “mid-level practitioners.” The proposed PFS defines “mid-level practitioners” as including physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse midwives. Application and enforcement of the Sunshine Act’s reporting requirements for mid-level practitioners is effective for all information required to be submitted to CMS on or after January 1, 2022.

CMS proposes condensing two existing payment reporting categories related to continuing education programs (serving as faculty or speaker for (i) accredited/certified programs; or (ii) unaccredited or noncertified programs) into a single category for reporting all faculty or speaker payments for medical education programs. CMS also proposes adding payment reporting categories for:

  • Debt forgiveness: transfers of value related to forgiving the debt of a covered recipient, a physician owner, or the immediate family member of the physician who holds an ownership or investment interest;
  • Long-term medical supply or device loans: loans of devices or supplies that last longer than 90 days; and
  • Acquisitions: buyout payments made to covered recipients in relation to the acquisition of a company in which the covered recipient has an ownership interest.

Finally, CMS proposed requiring device manufacturers to report device identifiers for each payment or transfer of value that is reported to CMS.

4. Proposed flexibility in the supervision requirements for physician assistants. CMS currently requires physician assistant services to be furnished under a physician’s general supervision, which is defined as being under the physician’s overall direction and control, though not necessarily in the physician’s presence. Based on public comments received by CMS, the level of independence of physician assistants rivals that of nurse practitioners in many parts of the country. In response, CMS proposes to permit physician assistants to practice in accordance with state law supervisory requirements, rather than under general physician supervision as required by CMS. In the absence of state laws governing physician assistant supervision, CMS proposes that the physician assistants supervision requirement be met “by documentation in the medical record of the physician assistant’s approach to working with physicians in furnishing their services.”

5. Proposed flexibility in documentation requirements. In order to ease the burden associated with medical record documentation, CMS proposes permitting physicians and non-physician practitioners to review and verify, rather than re-document, notes made in the patient medical record by other members of the medical team, such as nurses, students, and clinical staff. If finalized, this change is expected to decrease the documentation burden on practitioners, particularly clinical preceptors supervising medical and nursing students.

In addition to the significant proposals listed above, the proposed PFS also includes: (1) a minor adjustment to the RVU conversion factor from $36.04 in CY 2019 to $36.09 in CY 2020; (2) proposals related to changes in billing for care management; (3) a request for comments on potential changes to the Stark law advisory opinion process; and (4) changes to reimbursement for physical, occupational, and speech therapy services that are provided by a therapy assistant.

The proposed PFS is scheduled to be published in the Federal Register on August 14, 2019. CMS is accepting comments on the proposed rule through September 27, 2019.