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ACP: Proposed 2020 Medicare Physician Fee Schedule Embraces Reforms That Reflect Value of Primary Care

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The proposed Medicare Physician Fee Schedule includes important changes to evaluation and management codes, as well as updates to the Quality Payment Program and the Hospital Outpatient Prospective Payment System proposed rules

August 16, 2019 (ACP) – The Centers for Medicare & Medicaid Services (CMS) has released the proposed Medicare Physician Fee Schedule for 2020, and the American College of Physicians is pleased that officials have embraced important reforms that reflect primary care priorities in areas like evaluation and management (E/M) codes.

“CMS has proposed many positive improvements,” said Brian Outland, ACP's director of regulatory affairs. “It's clear that CMS is recognizing the value of primary care services and efforts to streamline and reduce documentation burdens in line with ACP's Patients Before Paperwork initiative.”

Among the most notable improvements, the proposed Physician Fee Schedule for 2020 would, if finalized, increase payments for E/M services. “ACP is very encouraged that CMS adopted recommendations from the Specialty Society Relative Value Scale Update Committee to increase payments for office/outpatient E/M visits starting in 2021,” Outland said. “Along with several other health care societies, ACP was a leader in this push to improve payments for these historically undervalued services.”

The E/M coding changes will also retain five levels of coding for established patients, reduce the number of levels to four for office/outpatient E/M visits for new patients, and update the code definitions. When documenting E/M services, the new changes will allow physicians to choose the E/M visit level based on medical decision-making or time spent. “We have long been seeking this flexibility,” Outland said. “The schedule also revises the medical decision-making process for all E/M codes and only requires performance of history and exam when medically appropriate.”

Accuracy in tracking time spent with a patient is also improved with the new proposed fee schedule. When time is tracked to determine the level of service, total time spent on all activities for a patient on the day of service is counted and physicians will no longer be required to spend more than 50 percent of the time on counseling and coordination of care. Instead, all the work for an E/M visit is considered equally valid and important, whether time is spent reviewing notes before entering the examination room or developing a differential diagnosis after the appointment ends.

As part of the new fee schedule, CMS proposes moving forward with plans for add-on coding because the revised E/M code set does not account for additional resource costs in furnishing primary care and certain specialty visits. “The agency is seeking comment on whether more than one code would be beneficial for this purpose,” Outland said.

CMS also plans to introduce a 15-minute, prolonged service code to take effect in 2021, which is another code ACP has long been advocating for, according to Outland.

“We applaud CMS for proposing these historic changes and look forward to working with regulatory leaders towards a plan that continues to address administrative and documentation burdens while ensuring quality patient care,” said Dr. Robert McLean, ACP's president.

CMS also released the proposed 2020 Quality Payment Program and Hospital Outpatient Prospective Payment System changes, and ACP plans to review each of these proposed plans. The Quality Payment Program proposed rule includes efforts to remove low-value measures, provisions for vendor accountability, and the new MIPS Value Pathway. The proposed Hospital Outpatient Prospective Payment System rule seeks to require hospitals to make gross charges and payer-specific negotiated charges public information and phase in site-neutrality provisions to align payment for off-campus hospital outpatient department visits with those of physician visits.

ACP has some reservations about certain aspects of the proposed QPP rule. “We have yet to see any meaningful accommodations for small, rural, and/or independent practices, which will likely fall further behind and be disproportionately penalized as a result of increases to the Merit-based Incentive Payment System (MIPS) performance threshold and exceptional performance threshold,” Outland said. “In past letters, we have suggested evaluating them separately with a separate performance threshold, up-front funding supports for technologies, or enabling them to report more easily through things like a free registry or online option.”

“ACP will be doing a full summary of the proposed rule and will submit formal comments to CMS, which are due September 27th,” Outland said. “ACP also will be meeting with administration officials to discuss our views on their proposals and plan to continue to communicate with members on how the proposals will impact them should they be finalized. Finally, we will wait for a final rule to be published later in the Fall.”

More Information

More detail on the proposed Medicare Physician Fee Schedule for 2020 is available in a fact sheet prepared by CMS.

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