Navigating health reform
Review of CMS’ 2020 Final Physician Fee Schedule Rule
This regulatory advisor was originally published on September 1, 2019 and covered the Proposed Physician Fee Schedule Rule. All updates were made to reflect the final rule.
On November 1, 2019, the Centers for Medicare & Medicaid Services (CMS) released the 2020 final Physician Fee Schedule (PFS) rule (CMS-1715-F), 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) are covered in a separate CLA Regulatory Advisor.
The following includes a high-level overview of key provisions in the final rule.
CMS finalizes 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 in 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. Overall, CMS was responsive to many stakeholder comments and adjusted various policies based on feedback.
Key payment updates
- The final conversion factor for 2020 is $36.0896 compared to $36.04 in 2019.
- The final conversion factor for anesthesia for 2020 is $22.2016 compared to $22.2730 in 2019.
- CMS finalized various coding and pricing changes on new scope equipment codes in 2020.
- CMS regularly reviews and updates new, revised, or misvalued codes. CMS finalizes 74 code groups, including adopting new online digital evaluation codes.
- CMS finalized two of the four codes listed as potentially misvalued: 3D-rendering radiology add-on code (76377) and external counterpulsation therapy (G0166).
Telehealth and virtual health expanded
New telehealth codes
CMS continues to expand the list of codes for using telehealth. In the final 2020 rule, the agency adds three new HCPCS G-codes for opioid use disorder:
- HCPCS code G2086: 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.
- HCPCS code G2087: 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.
- HCPCS code G2088: Office-based treatment for opioid use disorder, 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 discusses these telehealth codes in conjunction with the newly proposed Medicare Part B benefit for OUD provided by opioid treatment programs (OTPs), as well as in the new proposed bundled payment for office-based OUD. (Details are included below.)
Furthermore, 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 these codes complements the existing policies related to flexibilities in treating these conditions under Medicare telehealth.
For 2020, CMS also finalized the telehealth originating site fee of $26.25.
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 finalized the following changes:
- CPT code 99457 (Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; initial 20 minutes)
- CPT code 99458 (Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes). CMS finalized a RVU of 0.61 and finalized the RUC-recommended direct PE.
Both codes would fall 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, and 99452). In allowing for these codes, CMS also required under the 2019 final PFS rule that advance beneficiary consent is obtained for each of these services every time they were used, 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. Therefore, CMS finalized that a single consent is required at least annually for these services.
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. Three codes are for individuals who independently bill E/M services (99420 – 99422) and three codes for those who cannot (98970 – 98972). For 2020, CMS finalized separate payment for these online digital assessments as outlined below, including corresponding G codes.
- 99421 (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.
- 99422 (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.
- 99423 (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.
- 98970 (Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes).
- 98971 (Qualified nonphysician health care professional online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes).
- 98972 (Qualified nonphysician qualified health care professional online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes).
- HCPCS code G2061NPP1 (Qualified nonphysician health care professional online assessment and management, 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 G2062 (Qualified nonphysician health care professional online assessment and management 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 G2063 (Qualified nonphysician qualified health care professional assessment and management 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 finalized the direct PE inputs associated with CPT codes 98970 – 98972 to their respective G code.
Evaluation and management codes
View our webinar on CPT coding updates here.
Overall, CMS finalized adopting the new coding, prefatory language, and interpretive guidance framework that has been issued by the CPT Editorial Panel for CY 2021 for E/M office visits. CMS would retain the previous five code levels for established patients and four levels for new patients (99201 deleted). CMS also finalized revising the code definitions and level selection to now be based on time or medical decision-making (MDM) and requires performance of history and exam only as medically appropriate. These changes begin on January 1, 2021. Because CMS is no longer collapsing levels 2 – 4, its previous minimum documentation requirements are moot.
CMS finalized 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). CMS finalizes the work RVU of 0.61 for 99XXX. With adopting 99XXX in 2021, CMS concurrently deletes its previously finalized prolonged office visit code, GPRO1. CMS finalizes that CPT codes 99358 – 99359 will not be payable in association with office/outpatient E/M visits beginning in CY 2021. Also for 2021, CMS finalized complexity add-on code GPC1X. Finally, CMS does not accept the RUC recommendations for global surgical packages values, as CMS continues its own review of these.
CMS does provide estimates on the potential impact of the code changes in 2021, but these are only illustrative at this point. Those in family practice (12%), endocrinology (16%), rheumatology (15%), and hematology/oncology (12%) will gain the most. CMS estimates that 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 finalized billing for 14 codes and TCM service concurrently. The 14 codes were previously thought to have substantial overlap with TCM and, therefore, were not billable with TCM. CMS also added two additional codes for concurrent billing to the list: CPT codes 99490 and 99491. CMS finalized increased work RVUs of 2.36 for CPT code 99495 and 3.10 for CPT code 99496 for 2020.
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 — and originally proposed four new G codes for this purpose. However, due to stakeholder feedback about the potential burden of the proposed four new G codes and the ongoing work of the CPT Editorial Panel, CMS did not finalize three of the four codes.
For non-complex CCM, CMS had proposed adopting two new G codes — GCCC1 and GCCC2 — to be used for PFS payment instead of CPT code 99490. CMS finalized only GCCC2 (now G2058). CMS also placed a frequency limit on the code of two.
- G2058: Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure). (Do not report G2058 for care management services of less than 20 minutes additional to the first 20 minutes of chronic care management services during a calendar month). (Use G2058 in conjunction with 99490). (Do not report 99490, G2058 in the same calendar month as 99487, 99489, 99491).
For complex CCM, CMS had proposed adopting two new G codes — GCCC3 and GCCC4 — to be used for PFS payment instead of CPT codes 99487 and 99489. CMS did not finalize either code. Instead, CMS finalized that for CY 2020 it will continue to recognize CPT codes 99487 and 99489, but with a different care planning element for purposes of billing Medicare. Beginning in CY 2020, for PFS billing purposes for CPT codes 99487 and 99489, CMS interprets the code descriptor “establishment or substantial revision of a comprehensive care plan” to mean that a comprehensive care plan is established, implemented, revised, or monitored.
Typical CCM care plan
In order to clarify its policy, CMS finalized the following new language for a comprehensive care plan:
The comprehensive care plan for all health issues typically includes, but is 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.
Principal care management services (PCM)
In recognition that there is considerable time needed to manage one chronic condition (as opposed to multiple), CMS finalized a new PCM payment and coding structure using the following:
- G2064: 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 finalized a work RVU of 1.45.
- G2065: 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.
CMS also added a requirement that ongoing communication and care coordination between all practitioners furnishing care to the beneficiary must be documented by the practitioner billing for PCM in the patient’s medical record. CMS also finalized several changes to the PCM services requirements, which were built off CCM’s requirements to better reflect PCM services.
Opioid use disorder, opioid treatment program, and 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 opioid treatment programs (OTPs). CMS outlines its finalized implementation for this new benefit, as required by statute.
CMS finalizes the following for OUD treatment. In response to stakeholder feedback, CMS added intake activities and periodic assessments from its earlier proposal.
- 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 the 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 professionals to the extent authorized under state law).
- Toxicology testing
- Intake activities
- Periodic assessments
CMS finalized that counseling services and individual and group therapy services furnished via telehealth (synchronous) are permitted.
For OTPs, CMS finalized various Medicare-enrollment requirements and credentialing/accrediting requirements by the Substance Abuse and Mental Health Services Administration (SAMSHA). CMS notes that the home or other telehealth location can be an originating site.
With respect to payment, the SUPPORT ACT requires CMS to create a bundled payment for these OUD services provided by OTPs. CMS finalized its approach for the bundled payment.
- Episode of care is one week or seven continuous days.
- 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. A non-drug episode is created as well.
- CMS finalizes HCPCS codes for the primary service, G2067-G2075.
- CMS finalized five additional intensity add-on codes. This includes an add-on code created (G2080) 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. Another add-on code for intake activities (G2076) and one for periodic assessments (G2077) was finalized. CMS indicates to bill for these, it must be medically reasonable, necessary, and documented in the patient record. Two other codes (G2078 and G2079) reflect situations where there are take-home supplies of methadone and take-home supplies of oral buprenorphine.
- A new Place of Service code is created: Place of Service code 58 (Non-residential Opioid Treatment Facility — a location that provides treatment for OUD on an ambulatory basis. Services include methadone and other forms of MAT).
- CMS finalizes there will be no beneficiary cost-sharing amounts at this time.
As required by the SUPPORT Act, CMS would implement this benefit beginning January 1, 2020.
Substance use disorder 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 finalized the following for this bundle:
- Payment based on a monthly episode (not weekly like OTP/OUD)
- Three OUD codes (G2086, G2087, and G2088)
- Providers required to qualify under state law and operate within the scope of practice
- Billing clinician required to manage the 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 finalized its proposal 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 finalized two proposals related to the 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. CMS specifically states that any state law or state scope of practice rule that describes the relationship between physicians and PAs, including supervisory or collaborative requirements, are considered a form of supervision. For states with no explicit state law or scope of practice rules regarding physician supervision of PA services, the relationship is evidenced by documenting at the practice level the PA’s scope of practice and the working relationships with the supervision physician when furnishing services.
With respect to verification of medical record documentation, CMS finalized that physicians, PAs, nurse practitioners (NP), clinical nurse specialists (CNS), and certified nurse-midwives (CNM) may 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. CMS also explicitly names PAs and NPs, CNSs, CNMs, and Certified Registered Nurse Anesthetists students as APRN students, along with medical students, as the types of students who may document notes in a patient’s medical record that may be reviewed and verified rather than re-documented by the billing professional.
CMS finalized implementing 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 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.
CMS clarified that there is no CMS-prescribed form for physician certification statements for ambulance transports. CMS finalized with minor clarifications 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 finalized, in detail, its data collection approach for ground ambulance providers and suppliers, as required by the Bipartisan Budget Act (BBA) of 2018.
CMS finalized 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 the covered recipient. CMS also makes various changes to the nature of payment categories.
Expansion of NPPs to ASCs, hospice
CMS finalized allowing the use of non-physician practitioners (NPPs) to provide services in these settings as follows: for ASC conditions for coverage, CMS finalized permitting 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. CMS clarifies that there are two components to any pre-procedure evaluation and requires that, immediately before surgery, a physician must examine the patient to evaluate the risk of the procedure to be performed, and a physician or anesthetist must examine the patient to evaluate the risk of anesthesia. A physician may perform both parts of the pre-procedure evaluation. This would include permitting CRNAs to perform the anesthetic risk and evaluation on the patient in ASCs that use these NPPs. For hospice, CMS finalized allowing 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
CMS finalized several revisions to the process for issuing Advisory Opinions (AO), including modifications to acceptance of requests, timelines for issuing AOs, certification requirements, fees, reliance on AOs, and rescissions.
CMS also provided its annual list of updated CPT/HCPCS codes.
Intensive Cardiac Rehabilitation (ICR)
CMS finalized the addition of stable, chronic heart failure (CHF) to the list of covered conditions for ICR. CHF is defined as a patient with a left ventricular ejection fraction of 35% or less and NYHA class II to IV symptoms, despite being on optimal heart failure therapy for at least six weeks.
Medicare Shared Savings Program and Merit-Based Incentive Payment System (MIPS) alignment
CMS finalized several revisions to the MSSP quality measure set:
- Make ACO-17: Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention a pay-for-reporting measure for PY 2019 and revert back to pay-for-performance for performance in 2020.
- 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).
All total, there are 23 measures for PY 2020 across four domains.
How we can help
CMS finalized 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.