Regulatory Advisor 2020 Proposed PFS Rule

The proposed rule allows for more chronic care and opioid treatment, and further supports Medicare telehealth and virtual health options.

Navigating health reform

Review CMS’ 2020 Proposed Physician Fee Schedule Rule

  • Jennifer Boese
  • 9/10/2019

On July 29, 2019, the Centers for Medicare & Medicaid Services (CMS) released the 2020 proposed Physician Fee Schedule (PFS) rule (CMS-1715-P), which includes Evaluation and Management (E/M) coding updates, telehealth expansion, treatment and payment for opioid use disorder, and additional flexibility to address care management services. Updates to the Quality Payment Program (QPP) will be covered in a separate CLA Regulatory Advisor.

The following includes a high level overview of key provisions in the proposed rule. The comment deadline is September 27, 2019.

Key takeaways

CMS offers a package of coding changes intended to allow for more chronic care management, including a new principal chronic management code for individuals with one chronic condition. CMS furthers its efforts to support the use of Medicare telehealth and virtual health, including for the newly created Medicare benefit for Opioid Use Disorder (OUD). CMS also walks back its policy to collapse E/M codes 2 – 4 and will instead keep all five levels.

Key payment updates

  • The proposed conversion factor for 2020 is $36.09 compared to $36.04 in 2019.
  • The proposed conversion factor for anesthesia for 2020 is $22.2774 compared to $22.2730 in 2019.
  • For direct practice expense (PE), CMS has been interested in the use of scopes and video systems. CMS proposes to establish 23 new scope equipment codes in 2020. CMS seeks feedback on the codes and pricing.
  • CMS reviews 74 code groups and proposes various changes, including adopting six new online digital evaluations codes (details for E/M codes are covered in this article)
  • CMS proposes to look at four potentially misvalued codes, including fine needle aspiration codes (10005 and 10021), 3D-rendering radiology add-on code (76377), and external counterpulsation therapy (G0166).

Telehealth, virtual health expanded

New telehealth codes

CMS continues to expand the list of codes for using telehealth. In the proposed 2020 rule, the agency adds three new HCPCS G-codes for OUD:

  • HCPCS code GYYY1: Office-based treatment for OUD, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month.
  • HCPCS code GYYY2: Office-based treatment for OUD, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month.
  • HCPCS code GYYY3: Office-based treatment for OUD, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (list separately in addition to code for primary procedure).  

CMS believes that adding these codes will complement the existing policies related to flexibilities in treating substance use disorder (SUD) under Medicare telehealth.

Further, CMS reminds the reader of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act’s removal of geographic limitations for telehealth services furnished to individuals diagnosed with a SUD for the purpose of treating the SUD or a co-occurring mental health disorder. The SUPPORT Act also allows for a patient’s home to be an originating site. These changes were finalized under the 2019 PFS rule. CMS indicates it believes adding GYYY1, GYYY2, and GYYY3 will complement the existing policies related to flexibilities in treating these conditions under Medicare telehealth.

Remote physiological monitoring (RPM)

CMS adopted three codes for chronic care RPM in 2019 (99453, 99454, and 99457). The codes involve the collection, analysis, and interpretation of digitally collected physiologic data, followed by a treatment plan, and the management of a patient under the treatment plan. For 2020, CMS makes the following changes:

  • CPT 99457 would be used for the first 20 minutes of the treatment management service and then a new code, 994X0, would be used as an add-on code to cover additional 20 minute interval(s) of those services.
  • CPT code 994X0 would have a work Relative Value Unit (RVU) of 0.50. CMS proposes direct PE inputs for 994X0.
  • CPT code 99457 and 994X0 would be used under general supervision. CMS also states that the supervising provider does not need to be the treating provider, but that only the supervising provider may bill Medicare for incident to services.

Virtual communications advance consent 

In 2019, CMS provided new codes and requirements related to virtual communications, such as: evaluation of recorded video and/or images (HCPCS code G2010), virtual check-in (HCPCS code G2012), and six interprofessional consultation services (CPT codes 99446 – 99449, 99451, 99452). In allowing for these codes, CMS also requires under the 2019 final PFS rule that advance beneficiary consent be obtained for each of these services, given that there would be co-pays applied. Since then, CMS notes some stakeholders have expressed concern with the burden and difficulty in obtaining consent. CMS is now seeking comments on whether a single advance beneficiary consent could be obtained instead. And, if so, how much time or how many services for this single consent would be appropriate (e.g., six months, one year). CMS also seeks comments on what program integrity concerns may arise with these changes, and how best to minimize them.

Online digital evaluation services (e-visit)

In September 2018, the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel deleted two codes and replaced them with six new non-face-to face codes. These new codes describe patient-initiated digital communications that require a clinical decision that otherwise typically would have been provided in the office. For 2020, CMS proposes separate payment for these six online digital assessments as outlined below — three codes for individuals who independently bill E/M services and three codes for those who cannot.

  • 9X0X1 (Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes). Work RVU of 0.25
  • 9X0X2 (Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 11– 20 minutes). Work RVU of 0.50.
  • 9X0X3 (Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes). Work RVU of 0.80.
  • HCPCS code GNPP1 (Qualified nonphysician healthcare professional online assessment, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes). Work RVU of 0.25.
  • HCPCS code GNPP2 (Qualified nonphysician healthcare professional online assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes). Work RVU of 0.44
  • HCPCS code GNPP3 (Qualified nonphysician qualified healthcare professional assessment service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes). Work RVU of 0.69.

CMS proposes the direct PE inputs associated with CPT codes 98X00, 98X01, and 98X02, and for GNPP1, GNPP2, and GNPP3, respectively.

Evaluation and management codes

CMS does not propose any major changes to E/M office visit codes and payment for 2020; however, it reverses course in several ways from what it finalized in the 2019 PFS rule (to take effect in 2021). Instead of collapsing levels 2 – 4 E/M visits into one blended rate, CMS proposes to retain five levels of coding for established patients and reduce the number of levels to four for office/outpatient E/M visits for new patients.

Overall, CMS proposes to adopt the new coding, prefatory language, and interpretive guidance framework that has been issued by the CPT Editorial Panel for CY 2021. Accordingly, CMS also proposes to revise the code definitions and to revise level selection to be based on time or medical decision making (MDM), and requires performance of history and exam only as medically appropriate. Because CMS is no longer collapsing levels 2 – 4, its previous minimum documentation requirements are moot. Instead, when visit level is selected by MDM complexity, documentation guided by the MDM grid elements for that level would be expected. When visit level is chosen based upon time, documentation of the clinician’s total time for a patient on the visit date, and the medical necessity for the visit would be expected.

CMS proposes to adopt the AMA Relative Value Scale Update Committee (RUC)-recommended values for the office/outpatient E/M visit codes for CY 2021 (99202 – 99215) and the new add-on CPT code for prolonged service time (99XXX). With adopting 99XXX in 2021, CMS concurrently deletes its previously finalized prolonged office visit code, GPRO1. Also for 2021, CMS proposes to delete its previously finalized complexity add-on code, GCG0X, but to retain and revise GPC1X; the latter would be available as an add-on code to all office visits with inherent complexity. Finally, CMS does not accept the RUC recommendations for global surgical packages values, as CMS continues its own review of these.

Because the E/M coding changes will be budget neutral within the PFS, CMS estimates that those in family practice (12%), endocrinology (16%), and rheumatology (15%) will gain the most. CMS estimates that clinicians in ophthalmology (-10%); nurse anesthetists and chiropractors (-9%); and cardiac surgery, pathology, physical/occupational therapy and radiology (-8%) would see the largest decreases.

Care management codes expanded

CMS offers a package of coding changes intended to allow better coordinated care and care management of patients with one or multiple chronic conditions.

Transitional care management (TCM)

CMS believes there may not be substantial overlap between these 14 codes and TCM services; therefore, it proposes to allow TCM codes to be billed concurrently with any of these codes. CMS seeks comments on a variety of issues related to this proposal. CMS also proposes increased work RVUs of 2.36 for CPT code 99495 and 3.10 for CPT code 99496 for 2020. CMS does not propose any changes to the direct PE.

Chronic care management (CCM)

CMS agrees with stakeholder comments that coding changes to provide additional time increments would improve payment accuracy for CCM – both complex CCM and non-complex CCM.

For non-complex CCM, CMS proposes to adopt two new G codes – GCCC1 and GCCC2 – to be used for PFS payment instead of CPT code 99490. Those G codes are describes below.

  • GCCC1: CCM, initial 20 minutes of clinical staff time directed by a physician or other qualified health care profession, per calendar month with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until death; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation or functional decline; and comprehensive care plan established, implemented, revised or monitored. (CCM of less than 20 minutes, in a calendar month, are not reported separately.) CMS proposes a work RVU of 0.61. 
  • GCCC2: CCM, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care profession, per calendar month (List separately in addition to code for primary procedure) (Use GCCC2 in conjunction with GCCC1). (Do not report GCCC1, GCCC2 in the same calendar month as GCCC3, GCCC4, 99491.) CMS proposes a work RVU of 0.54.

For complex CCM, CMS proposes to adopt two new G codes — GCCC3 and GCCC4 — to be used for PFS payment instead of CPT codes 99487 and 99489. The G codes are described as follows:

  • GCCC3: CCM services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until death; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation or functional decline; comprehensive care plan established, implemented, revised or monitored; moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month. (CCM services of less than 60 minutes duration, in a calendar month, are not reported separately)). CMS proposes a work RVU of 1.00.
  • GCCC4: each additional 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month. (List separately in addition to code for primary procedure). (Report GCCC4 in conjunction with GCCC3) (Do not report GCCC4 for CCM of less than 30 minutes additional to the first 60 minutes of complex CCM during a calendar month). CMS proposes a work RVU of 0.5.

CMS seeks comments about these G codes, particularly about whether the benefit of proposing G codes outweighs the burden of transition to their use before a decision is made by the CPT Editorial Panel.

Principal care management services (PCM)

In recognition that there is considerable time needed to manage one chronic condition (as opposed to multiple), CMS proposes a new PCM payment and coding structure using the following:

  • GPP1: CCM for a single high-risk disease, e.g. PCM, 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 3 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. CMS proposes a work RVU of 1.28.
  • GPP2: CCM for a single high-risk disease, e.g. PCM, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting at least 3 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. CMS proposes a work RVU of 0.61.

Typical care plan

In order to clarify its policy, CMS proposes the following new language for a comprehensive care plan:

The comprehensive care plan for all health issues typically includes, but it not limited to, the following elements: problem list; expected outcome and prognosis; measurable treatment goals; cognitive and functional assessment; symptom management; planned interventions; medical management; environmental evaluation; caregiver assessment; interaction and coordination with outside resources and practitioners and providers; requirements for periodic review; and when applicable, revision of the care plan.

Opioid Use Disorder, Opioid Treatment Program benefit, Bundled payment

The SUPPORT Act created a new Medicare Part B benefit for OUD treatment services, including medications for medication-assisted treatment (MAT) furnished by OPTs.

The SUPPORT Act includes the following definition for OUD treatment, and CMS proposes the same:

  • Opioid agonist and antagonist treatment medications (including oral, injected, or implanted versions) that are approved by the Food and Drug Administration (FDA) under section 505 of the Federal, Food, Drug, and Cosmetic Act for use in treatment of OUD.
  • Dispensing and administration of such medications, if applicable.
  • Substance use counseling by a professional to the extent authorized under state law to furnish such services.
  • Individual and group therapy with a physician or psychologist (or other mental health professional to the extent authorized under state law).
  • Toxicology testing

The statute provides flexibility for CMS to add other appropriate services to this definition, and CMS proposes to add counseling services and individual and group therapy services furnished via telehealth (synchronous).

For OTPs, CMS proposes various Medicare-enrollment requirements and credentialing/accrediting requirements by the Substance Abuse and Mental Health Services Administration (SAMSHA). For these OTPs, CMS also proposes they would be able to furnish the substance use counseling, individual therapy, and group therapy services via two-way interactive audio-video communication technology (synchronous), as clinically appropriate. CMS states it believes these telehealth policies can increase access, including to rural communities or health professional shortage areas.

With respect to payment, the SUPPORT ACT requires CMS to create a bundled payment for these OUD services provided by OTPs:

  • Episode of care is one week or seven continuous days. A partial episode is also created.
  • OTPs may bill a full week if providing at least 51% of services (otherwise a partial episode could be billed)
  • Payment would include a drug component and a non-drug component
  • Bundled payment (and coding structure) would vary depending on the type of drug used
  • 18 OTP code descriptors created (for full and partial episodes based on drug and services) and approximate payments amounts provided
  • Geographic Adjustment factor (GAF) applied to the bundle (not to the drug portion)
  • One add-on code created (HCPCS code GXX19) for each additional 30 minutes of counseling or group or individual therapy provided during a week, exceeding the amount specified in the treatment plan. Medical necessity must be documented.
  • A new Place of Service code is created.

As required by the SUPPORT Act, CMS would implement this benefit beginning January 1, 2020.

Substance use disorder bundled payment

Similar to the OUD/OTP bundled payment, CMS also proposes another bundled payment for office-based OUD treatment. This bundle would include management, care coordination, psychotherapy, and counseling. Drugs would not be included in this bundle, but would continue to be paid as usual under their respective payment mechanism. A consultation with a specialist would not be required in order to receive payment. CMS proposes the following for this bundle:

  • Payment based on monthly episode (not weekly like OTP/OUD)
  • Three OUD codes (GYYY1, GYYY2, and GYYY3)
  • Providers required to qualify under state law and operate within scope of practice
  • Billing clinician required to manage patient’s overall care
  • Therapy and counseling services can be provided via telehealth if clinically appropriate

Key policy updates

Supervision of physician assistants (PAs) and verification of medical record documentation

CMS proposes to establish a general principle to allow the physician, the PA, or the advanced practice registered nurse (APRN) who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students, or other members of the medical team. CMS states that this principle would apply across the spectrum of all Medicare-covered services paid under the PFS.

CMS is proposing to relax regulatory requirements with respect to supervision of PAs and documentation of medical records for some non-physician professionals. Under the first proposal, PAs would gain greater flexibility to practice more broadly in accordance with state law and state scope of practice. In the absence of state laws governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be satisfied by documentation in the medical record of the PA’s approach to working with physicians in furnishing their services.

CMS would also allow physicians, PAs, nurse practitioners (NP), clinical nurse specialists (CNS), and certified nurse-midwives (CNM) to sign and date, rather than re-document, notes made in a medical record by other physicians, residents, nurses, students, or other members of the medical team. CMS indicates this is in response to commenters to its Patients over Paperwork request for information.

Therapy services

CMS proposes to implement claims modifiers to identify therapy services furnished in whole or in part by a physical therapy assistant (PTA) and occupational therapy assistant (OTA), as required by statute. CMS would apply a 10% de minimis standard for when the modifier will apply to specific services. Beginning in 2022, the modifiers will trigger a reduced payment rate for outpatient therapy services furnished in whole or in part by a PTAs or OTAs. The payment reduction will not apply to services provided in Critical Access Hospitals. CMS provides details on how the modifiers (CO/CQ) would be applied based on untimed or timed units of service.

Ambulance services

CMS clarifies that there is no CMS-prescribed form for physician certification statements for ambulance transports. CMS is also proposing to grant ambulance suppliers and providers greater flexibility around who may sign a non-physician certification statement in certain circumstances. The proposal would also add licensed practical nurses (LPNs), social workers, and case managers as staff members who may sign the non-physician certification statement if the provider or supplier is unable to obtain the attending physician’s signature within 48 hours of the transport. In addition, CMS proposes its data collection approach for ground ambulance providers and suppliers, as required by the Bipartisan Budget Act (BBA) of 2018.

Open Payments

CMS proposes a number of changes to the Open Payments regulations, including adding NPs, PAs, CNSs, Certified Registered Nurse Anesthetists (CRNAs), and CNMs to the definition of covered recipient. CMS also proposes to collapse two medical education categories and add three new categories going forward (debt forgiveness, long-term medical supply or device loans, and acquisitions).

Expansion of NPPs to ASCs, hospice

CMS proposes to allow the use of non-physician practitioners (NPPs) to provide services in these settings as follows: for ASC conditions for coverage, CMS proposes to permit a physician or an anesthetist to examine a patient immediately before surgery to evaluate the risk of anesthesia and risk of the procedure to be performed. This would include permitting CRNAs to perform the anesthetic risk and evaluation on the patient in ASCs that use these NPPs. For hospice, CMS proposes to allow a hospice to accept drug orders from PAs acting within their state scope of practice and hospice policy, along with several other requirements.

Stark Law advisory opinions

While CMS has not issued updated guidance on the Stark physician self-referral law, it is seeking additional comment on potential revisions to the process for issuing Advisory Opinions (AO) on the law. CMS said commenters responding to a broader request for information on Stark urged it to change the parameters under which an AO is issued to provide better clarity on Stark compliance. Currently, the opinions are issued on a case-by-case basis only.

Intensive Cardiac Rehabilitation (ICR)

CMS proposes to add stable, chronic heart failure (CHF) to the list of covered conditions for ICR. CHF is defined as a patient with left ventricular ejection fraction of 35 percent or less and NYHA class II to IV symptoms, despite being on optimal heart failure therapy for at least 6 weeks.

Medicare Shared Savings Program and Merit-Based Incentive Payment System (MIPS) alignment

CMS invites comments on how to better align quality scoring for MIPS with Accountable Care Organizations (ACOs) operating in the Medicare Shared Savings Program (MSSP). CMS said it recognizes that ACOs are making significant investments and wants to help ACOs better target resources towards improving care.

CMS proposes to revise the MSSP measure set with the following changes:

  • Remove ACO-14: Preventive Care and Screening Influenza Immunization for PY 2020
  • Add ACO-47: Adult Immunization Status with pay-for-reporting for PYs 2020 and 2021, fully phasing to pay-for-performance in PY 2022
  • Make ACO-17: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention a pay-for-reporting measure for PY 2019 and forward
  • Update ACO-43: Ambulatory Sensitive Condition Acute Composite (AHRQ Prevention Quality Indicator [PQI] #91) to remove dehydration. The updated measure will only include bacterial pneumonia and urinary tract infection. Since this is a large change, according to CMS policy, the agency proposes to make ACO-43 pay-for-reporting for two years (2020 and 2021).

CMS seeks comment on how to align the MSSP and MIPS quality performance scoring methodologies to reduce administrative burden and allow ACOs to use resources more efficiently, including the following options: 

  • Potentially use MIPS quality performance category score to assess quality performance for purposes of the MSSP quality performance standard
  • Use all of the MIPS claims-based measure in the MIPS quality performance category score for ACOs, using this score in place of the current Shared Savings Program for all ACOs.
  • Determine MSSP quality minimum attainment using MIPS data
  • Use MIPS quality performance category score or an alternative score in determining shared savings or shared losses under MSSP

How we can help

CMS is proposing new or improved reimbursements for care management, telehealth/virtual health and opioid use treatment, which could help address key access needs while providing sustainable reimbursement opportunities for physicians and other providers. CLA can help you evaluate how these developments will impact your organization.