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Jerris Heaton

Helping You Navigate CMS’s Proposed Rule for 2020

September 10, 2019

Clinician, News 7 Minute Read

The Centers for Medicare & Medicaid Services (CMS) proposes regulations every year impacting the reimbursement of physicians under the Medicare Physician Fee Schedule (PFS). On July 29, 2019, the CMS issued a proposed rule updating relevant payment policies and rates that will go into effect either on or after January 1, 2020. This strategy aims to reflect a broader Administration-wide approach to creating a healthcare system that fosters better accessibility, quality, affordability, empowerment, and innovation.

As your partner in navigating regulatory modifications, ChartLogic has compiled a brief Physician Fee Schedule 2020 summary that will help our provider-partners be aware of how their practices will be impacted while preparing them for the upcoming year.

Conversion Factor

Remaining relatively unchanged, CMS proposes to increase the physician conversion factor by $0.05 from 2019 to $36.09 in 2020, with no increase coming via the Medicare Access and CHIP Reauthorization Act (MACRA).

Quality Payment Programs (QPP)

Updates to the Quality Payment Program include the Merit-Based Incentive Payment System (MIPS) as well as the Alternative Payment Model (APM) tracks, and as in previous years, the weighting, requirements, and categories for the MIPS have been adjusted for the 2020 performance year. Of the 100 MIPS points available, Quality will now account for 40%, cost for 20%, Promoting Interoperability for 25%, and Improvement Activities for 15%. Also, the proposed performance threshold will be raised from 30 points in 2019 to 45 total MIPS points in 2020. Those practices who either fail to participate when required or do not meet the new threshold may incur up to a 9% payment adjustment in 2022. Additionally, an increase in the MIPS Quality threshold from 60% of eligible cases per measure to 70% of eligible cases has also been proposed. And to garner greater and more rapid feedback as well as to gain more participation in the MIPS, beginning in 2021, a new framework will take effect called the MIPS Value Pathways (MVPs), aimed at aligning the four MIPS components based on specialty or condition, reduce administrative burden, and facilitate the transition into Advanced Alternative Payment Models (APMs).

Further, proposing a 2.7% increase in Outpatient Prospective Payment System (OPPS), the CMS estimates that, when compared to 2019, there will be approximately $6 billion higher in total payments to OPPS providers next year.

Moreover, as a result of President Trump’s recent Executive Order on price and quality transparency that lays the foundation for a patient-driven healthcare system and in-line with agency’s previous price transparency initiatives, the CMS rule will require hospitals to publish payer-specific negotiated rates for 300 services consumers are likely to shop for, including 70 defined by CMS, in both a searchable and consumer-friendly manner. Those facilities that fail to comply could be fined up to $300 a day. The proposed rule will also finish the implementation of the policy adopted last year that makes payments for clinic visits site-neutral by reducing the payment rate to 40% of the OPPS rate for hospital outpatient clinic visits provided at off-campus provider-based departments.

Evaluation/Management (E/M) Visits

The proposed 2020 rule will allow for separate payment rates for all five levels of coding for outpatient E/M visits—five levels for established patients and a reduction to four for new patient office/outpatient E/M visits—while allowing clinicians to choose E/M visit levels using either

medical decision making or time. Further, CMS proposes to implement an add-on code for

prolonged service time and a separate add-on code to recognize the complexity inherent to E/M services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition.

Physician Assistant (PA) Supervision Requirements

So that PAs have greater flexibility to practice more widely within the healthcare arena, CMS is proposing modifications to regulations governing physician supervision of these professionals by following state law and state scope of practice. However, in the absence of State law, Medicare requires that physician supervision of a PA be substantiated via documentation within the medical record of the PA’s approach to the services furnished.

Medical Record Review and Verification

To reduce the physician or practitioner burden of re-documenting notes made by other medical team members, CMS has proposed reforms to documentation policy. These reforms will allow physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives to review and sign off on notes made in medical records by other physicians, residents, nurses, students, or other medical team members, rather than re-documenting. 

Care Management Services

The CMS has proposed to increase Transitional Care Management (TCM) payments for care management services provided after a patient is discharged from either an inpatient stay or certain outpatient stays. Further, the agency has also proposed to replace specific Chronic Care Management (CCM) services with a set of Medicare-developed HCPCS G codes. This will allow clinicians to bill incrementally to reflect additional time and resources required to help provide care coordination and management services for those with multiple chronic conditions over a calendar month period while enabling more time to better distinguish complexity of illness. Reducing the burden of complex CCM code billing, the CMS is also proposing to adjust certain billing requirements and elements of the care planning services. Moreover, there is also a proposal to create new coding for Principal Care Management (PCM) services, which would pay clinicians for delivering care management for patients with a single serious and high-risk condition.

Bundled Payments

To allow for significant flexibility in delivered care and expand the concept of bundling to improve payment for services that will align with CMS’ accountability and efficiency improvement goals, the agency is soliciting comments that will enable CMS decision-making, regarding payment for services based on of the resources required to furnish said services.

Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs

As established in section 2005 of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, the CMS has recommended several proposals to meet the statutory requirements for the Medicare B benefit for opioid use disorder (OUD) treatment services allowing for medications for medication-assisted treatment (MAT) furnished by opioid treatment programs (OTPs). Under the CMS 2020 rule, providers must:

  1. Supply both clear definitions and enrollment policies of their OTP and OUD treatment services
  2. Provide their methodology and estimated bundled payment rates for OTPs that vary by the medication used to treat OUD and service intensity, and by full and partial weeks
  3. Adjust the bundled payments rates for geography and annual updates
  4. Enable the flexibility to deliver counseling and therapy services described in the bundled payments via two-way interactive audio-video communication technology as clinically appropriate
  5. Allow for a zero-beneficiary copayment for a time-limited duration

Bundled Payments for OUDs and Substance Use Disorders (SUDs)

To create new coding and payment for a bundled episode of care for OUD management and counseling, the CMS is proposing new codes describing a monthly bundle of services, including overall management, care coordination, individual and group psychotherapy, and substance use counseling. The initial month of treatment would be harnessed under one code to include assessments and treatment plan development. Another code would address subsequent months of treatment. And an add-on code would cover additional counseling. CMS is also proposing that the individual psychotherapy, group psychotherapy, and substance use counseling included in these codes could be furnished as Medicare telehealth services using communication technology as clinically appropriate.

Additionally, CMS is seeking comments as to whether the agency should consider making separate payments for SUD services and/or MAT services in the emergency department setting, including initiation of MAT, the potential for administration of long-acting MAT agents, and the potential for either referral or follow-up care, in future rulemaking.


Beginning January 1, 2020, modifiers established in the final CY 2019 PFS rule to identify therapy services that are furnished in whole or in part by physical therapy (PT) and occupational therapy (OT) assistants will be required by statute to be reported on claims.

Upcoming 2020 MIPS Webinar

ChartLogic and Healthmonix will be hosting a Navigating MIPS 2020 webinar this month on September 25th at 11:00 AM MST. We will be covering all of the proposed changes, what it means for physicians, and what you can do to help your practice be successful during the 2020 reporting year. We hope to see you there! Register for the webinar here.


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