The Centers for Medicare & Medicaid Services (CMS) annually issues proposed rules that update payment and quality program policies for services that physicians and their facilities provide. On July 29, CMS released the calendar year (CY) 2020 Medicare Physician Fee Schedule (MPFS)/Quality Payment Program (QPP) Proposed Rule, and the CY 2020 Outpatient Prospective Payment System (OPPS)/Ambulatory Surgery Center (ASC) Proposed Rule. Both rules include provisions that, if finalized, could greatly affect the delivery of surgical care.
CY 2020 MPFS Proposed Rule
The following is a summary of the major policies in the MPFS Proposed Rule that would affect physician payment.
Payment provisions
The MPFS updates payment policies, payment rates, and quality provisions for services furnished on or after January 1. CMS estimates a 0 percent impact on total allowed charges for general surgery services relative to its proposals for CY 2020.
In this proposed rule, the agency introduces various changes related to office/outpatient evaluation and management (E/M) visits, which would become effective in 2021. CMS proposes to align Medicare’s office/outpatient E/M coding with changes laid out by the Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits as follows:
- Retain five levels of coding for established patients and reduce the number of levels to four for new patients
- Eliminate history and physical as elements for E/M code selection, allowing clinicians to choose the E/M visit level based on either medical decision making or time
- Create add-on codes for prolonged services and for primary care/non-procedural specialty care
CMS also proposes to increase the values of most office/outpatient E/Ms, per recommendations from the American Medical Association/Specialty Society Relative Value Scale Update Committee (AMA RUC), but will not apply these increases to global surgery codes.
In addition, CMS proposes broad modifications to its review and verification of medical record documentation policies, such that certain nonphysician health care professionals (such as physician assistants [PAs], nurse practitioners, clinical nurse specialists, and certified nurse-midwives) could sign and date (that is, review and verify)—rather than redocument—notes that the attending physician or other members of the patient care team made in the medical record. The rule also includes proposals that would increase states’ authority to create and enforce laws governing the level of physician oversight for PA services and would revise existing Medicare regulations to specify that the physician supervision required by CMS for PA services could be evidenced by documentation of the PA’s role in furnishing such services in the medical record.
CY 2020 Quality Payment Program
The CY 2020 MPFS proposed rule also includes proposed updates to the 2020 Quality Payment Program (QPP). QPP implementation began in 2017, as directed under the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act of 2015 (MACRA). The program aims to incentivize the transition from fee-for-service to value-based care by tying payments more closely to the quality and cost of care with the goal for all providers to participate in Alternative Payment Models (APMs). The QPP will begin its fourth performance year January 1, 2020.
The QPP proposed rule includes updates to both the Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) pathways; however, the most notable proposal is a new framework for MIPS participation called MIPS Value Pathways (MVP). CMS describes MVP as a way to move away from the siloed activities and measures in the current MIPS program toward a framework that aims to align measures and activities based on conditions and specialties. The agency is of the view that implementing MVP will better prepare clinicians to transition to risk-based APMs by having a better understanding of quality and cost for a condition. CMS solicits substantial feedback from stakeholders to assist in the development of the framework. If finalized, the MVP would be implemented beginning with the 2021 performance period.
In addition to the MVP proposal, some major programmatic proposed changes in the rule include increasing the overall MIPS threshold, increasing the Cost and decrease the Quality performance category weights, and establishing a higher data completeness threshold for quality reporting. In CY 2020, surgeons participating in MIPS would need to meet CMS’ proposed 45-point performance threshold across the four categories to avoid a penalty in 2022, which is a 15 point increase from 2019. The agency also continues to focus on interoperability and advancing the use of health information technology through the Promoting Interoperability performance category. More information about the QPP and participation in programs can be found in the CMS QPP Resource Library.
CY 2020 OPPS/ASC proposed rule
CMS also released the proposed CY 2020 OPPS/ASC payment rule July 29. The agency projects an overall 2.7 percent payment increase for both hospital outpatient departments (HOPDs) and ASCs in CY 2020. Per the requirements in a June 2019 Executive Order, Improving Price and Quality Transparency in American Healthcare to Put Patients First, CMS proposes that hospitals make their standard charges for a set of “shoppable services” (that is, a service that a patient can schedule in advance) available online. The intent is for standard charges to be available in such a way that patients easily can locate and access payor-specific negotiated rates and associated data elements for these services.
In the rule, the agency also encourages site-neutral payment between certain Medicare outpatient care settings by continuing to cap the OPPS payment made for office visits in off-campus provider-based departments at the PFS-equivalent rate. CMS asserts that this payment policy, which will be fully implemented in 2020, will be a method to control unnecessary increases in the volume of services paid under the OPPS because all outpatient clinic visits delivered at off-campus PBDs will be reimbursed on a site-neutral basis at rates that are equivalent to physician offices.
In addition, CMS proposes to change the minimum required level of supervision for hospital outpatient therapeutic services from direct supervision to general supervision. Under this proposal, Medicare rules would require that a given procedure be furnished under a physician’s overall direction and control, but not that the physician be present during the procedure.
The rule also includes updates to quality measures included in both the Hospital Outpatient Quality Reporting Program (OQR) and Ambulatory Surgical Center Quality Reporting (ASCQR) Program. CMS proposes to adopt one claims-based outcome measure in the ASCQR Program for the CY 2024 payment determination that measures unplanned hospital visits within seven days of any general surgery procedure performed in an ASC. The measure was developed in conjunction with two other measures already finalized for inclusion in the ASCQR program that measure the same patient outcomes and use the same risk adjustment methodologies, but focus on orthopaedic and urology ASC procedures. Additionally, CMS solicits feedback on the potential adoption of four patient safety measures for future years of the OQR. The four patient safety measures discussed in the proposed rule previously were adopted in the ASCQR.
The American College of Surgeons Regulatory and Quality Affairs team is working to evaluate and produce written comments on these proposed rules. For more information, contact regulatory@facs.org.
