New payment policy, coding, and reimbursement changes set forth in the 2020 Medicare physician fee schedule (MPFS) final rule will take effect January 1. The MPFS, which the Centers for Medicare & Medicaid Services (CMS) updates annually, lists payment rates for Medicare Part B services and introduces or modifies other regulations that affect physician reimbursement and quality measurement. The American College of Surgeons (ACS) submitted comments on September 10 in response to the CMS MPFS proposed rule issued earlier in the year. Some provisions in the final rule, released November 1, incorporate changes recommended by the ACS. Although the final rule includes important payment and policy changes that affect all physicians, this article focuses on updates that are particularly relevant to general surgery and its related specialties.
E/M office/outpatient visits
CMS finalized changes to its coding and reimbursement policies for office/outpatient evaluation and management (E/M) visits to align with those developed by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel. Beginning in calendar year (CY) 2021, the agency will retain the five-level office/outpatient E/M coding system for established patients and reduce the number of levels to four for new patient visits. CMS will adopt revised E/M code definitions created by the CPT Editorial Panel, which eliminate history and physical exam as elements for E/M code selection and allow physicians to choose the E/M visit level based on the extent of their medical decision making or on time spent with the patient. The agency also will implement an add-on code for office visits that are part of ongoing primary care and/or management of patients with serious or complex conditions. Additionally, CMS accepted the AMA Specialty Society Relative Value Scale Update Committee’s (RUC)-recommended payment rates for office/outpatient E/Ms for CY 2021, which will increase the values of most of these services. However, the agency will not apply such increases to postoperative E/M visits that are bundled into 10- and 90-day global surgical packages.
Review and verification of medical records
CMS modified its existing medical record documentation regulations to specify that, when furnishing and billing for their professional services, physicians, physician assistants, and advanced practice registered nurses may review and verify (that is, sign and date) notes in a patient’s medical record that other physicians, residents, nurses, students, or other members of the medical team have made, rather than fully redocumenting the information. This policy will be applicable across the spectrum of Medicare-covered services paid under the MPFS in all settings.
Coinsurance for colorectal cancer screening tests
CMS solicited comments on a proposal that would require physicians to give advance notice to patients scheduled for screening colonoscopies that coinsurance may apply should the “screening” procedure turn into a “diagnostic” procedure if polyps are discovered and removed during the service. The ACS recognized the agency’s efforts to educate physicians and patients about cost-sharing obligations in order to mitigate instances of surprise billing but said that the onus is on CMS—not on physicians—to inform its beneficiaries about any potential out-of-pocket expenses. The agency will conduct a comprehensive review of its outreach materials to determine whether Medicare policies on payment and coverage for screening colonoscopies can be made clearer and more easily accessible.
Medicare enrollment denial and revocation
Under existing law, CMS may revoke a physician’s Medicare enrollment if he or she has a pattern or practice of prescribing Part D drugs that is abusive, represents a threat to the health and safety of beneficiaries, or fails to meet Medicare requirements. The proposed rule called for expanding this law to ensure patient safety. The final rule permits CMS to revoke or deny a physician’s Medicare enrollment if he or she has been subject to prior action from a state oversight board, federal or state health care program, Independent Review Organization, or any equivalent government body or program that oversees, regulates, or administers the provision of health care services if the underlying facts reflect improper physician conduct that led to patient harm. The agency specified that this policy will apply to all physicians in all settings under all Medicare programs for cases in which the physician’s behavior and the consequent patient harm was significant.
For more information on the CMS final rule and ACS advocacy efforts, contact regulatory@facs.org.
