New proposals that include making significant changes to evaluation and management (E/M) and chronic care management services in 2020 were recently released by the Centers for Medicare & Medicaid Services (CMS). The CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies aim to reduce administrative burdens, improve health outcomes, and provide greater flexibility and increased accuracy in medical coding for these services. As a medical billing outsourcing company, we keep track of changing industry rules and updates that impact healthcare providers. Let’s take a look at six key proposals in the CY 2020 PFS:

  • Update in physician fee schedule rate: The conversion rate for Medicare physician reimbursement will see a slight increase to $36.09 from the CY 2019 conversion factor of $36.04.
  • E/M services: The proposed changes include new E/M codes created by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for use in office and outpatient settings. CMS’s proposals include:
    • The new rule proposes adeparture from blended payment rates for established patient office visits coded as E/M levels 2 through 4 that CMS had finalized in the 2019 rule. CMS proposes to revert to separate codes and payment rates for the five E/M levels, while reducing the number of levels to four for office/outpatient E/M visits for new patients. In the rule, CMS noted that decision to reverse the blended payment rate was made after providers expressed concerns that it would inappropriately incentivize multiple or shorter patient visits, which could lead to providers treating less complex patients.
    • Theselection of the E/M code level would based on visit duration or medical decision-making and would only require performance of history and exam as medically appropriate.
    • E/M code definitions will be revised align with the CPT Editorial Panel’s recommendations.
    • The add-on CPT code for prolonged service time in E/M services is proposed to be retained, including the ability to use this add-on code for primary care and non-procedural specialty services that are part of ongoing management of a patient’s chronic condition(s).
    • The proposal also includes merging two Medicare-specific add-on codes for primary care and non-procedural specialty care visits that were finalized in CY 2019 into a single code for implementation in CY 2021.
  • Telehealth: CMS is proposing 3 new three HCPCS G-codes for telehealth services for opioid treatment programs (OTPs). These HCPCS codes, which describe a bundled episode of care for treatment of opioid use disorder, are as follows:
    • GYYY1: Office-based treatment for opioid use disorder, including the development of the treatment plan, care coordination, individual therapy, and group therapy and counseling; at least 70 minutes in the first calendar month.
    • GYYY2: 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.
    • GYYY3: 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 notes that adding HCPCS codes GYYY1, GYYY2, and GYYY3 will complement the existing policies related to flexibilities in treating substance use disorders (SUDs) under Medicare Telehealth.

  • Care Management Services: The types of chronic conditions that are eligible for care management services include mental health or behavioral health conditions, including SUDs. CMS proposes toincrease payment and billing flexibility for care management provided to beneficiaries after discharge from inpatient and certain outpatient stays.

It is also proposed to improve the accuracy of payment for chronic care management services and simplify medical billing for these services, and to introduce new coding and payment for care management services for patients with a single serious chronic condition.

CMS states, “In this proposed rule, we continue our ongoing work in this area through code set refinement related to transitional care management (TCM) services and chronic care management (CCM) services, in addition to proposing new coding for principal care management (PCM) services, and addressing chronic care remote physiologic monitoring (RPM) services”.

  • Merit-based Incentive Payment System: The new rule alsoproposes updates to the Merit-based Incentive Payment System for the CY 2020 reporting period. This includes a higher weight on cost measures and higher performance standards for earning positive payment adjustments. CMS proposes to start implementing the new MIPS Value Pathways in CF 2020 which is expected to reduce and align reporting requirements across the four MIPS performance categories over time.
  • Physician documentation: In continuation with changes in the 2019 PFS rule related to teaching physician documentation, CMS now proposes to allow physicians and certain non-physician practitioners to review and verify, instead of re-documenting notes made in the medical record by other members of the medical team.

In continuation with changes in the 2019 PFS rule related to teaching physician documentation, CMS now proposes to allow physicians and certain non-physician practitioners to review and verify, instead of re-documenting notes made in the medical record by other members of the medical team.

Revenue Cycle Intelligences reported that major industry stakeholders, including the American Medical Association (AMA) are upbeat about CMS’s proposed changes to E/M codes and payment. AMA President A. Harris, MD, MA said, “The proposed changes to documenting and coding for office visits will streamline reporting requirements, reduce note bloat, improve workflow, and contribute to a better environment for health care professionals and their Medicare patients” (www.revcycleintelligence.com).

The proposed rule, which will have significant implications for medical billing and coding will be published on August 14. CMS will accept comments on the proposed changes until September 27, 2019.