Health Reform WK-EDGE CMS tackles care management, administrative burden, with 2020 PFS proposal
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Friday, August 16, 2019

CMS tackles care management, administrative burden, with 2020 PFS proposal

By Bryant Storm, J.D.

CMS plans to give physicians enhanced evaluation and management payments to improve care coordination and improve patient outcomes.

Additional payments for evaluation and management (E/M) services, a new Value Pathway for the Merit-based Incentive Payment System (MIPS), and the removal of unnecessary administrative burdens are among the changes proposed in CMS’ Physician Fee schedule (PFS) proposed rule for calendar year (CY) 2020. CMS is proposing a conversion factor of $36.09, a slight increase above the CY 2019 conversion factor of $36.04. The proposed rule also includes proposals to clarify opioid treatment and relax physician supervision requirements for physician assistants (PAs). CMS is accepting comments on the proposals through September 27, 2019 (Final rule, 84 FR 40482, August 14, 2019).

Payment update. CMS is proposing to raise the relative value conversion—the basis for PFS reimbursement—from $36.04 to $36.09. The PFS is based upon national relative value units (RVUs). These values are multiplied by a conversion factor (CF) to convert the RVUs into payment rates. The RVUs represent the relative resources which are typically required to furnish a service.

E/M. The proposal seeks to increase the value of E/M codes for office/outpatient visits. CMS is hoping to provide enhanced payments for the evaluation of a patient, so that physicians can spend more time coordinating patient care, and, in theory, improve patient outcomes. The E/M updates are focused particularly on physicians who provide Chronic Care Management (CCM) services, or manage patients with multiple comorbidities—for example, diabetes and heart disease.

CMS is also proposing to support care management by increasing payments to practitioners for Transitional Care Management (TCM), or time they spend on care management after a patient leaves the hospital. CMS is also proposing to pay for Principal Care Management (PCM), the care management of patients with a single, high-risk chronic condition. The agency is hoping to improve the continuity of care for these high-risk patients.

Quality. In order to reduce the reporting burden associated with the Quality Payment Program, CMS is proposing the MIPS Value Pathways (MVPs). Under the proposal, beginning in 2021, physicians will report on a smaller, specialty- specific measure set, which will be outcome-based. Under the simplified reporting structure, CMS projects that it will be able to more quickly provide physicians with feedback on their performance.

CMS is also accepting comments as to how it can better align the scoring methodology from the Medicare Shared Savings Program with the MIPS quality performance scoring methodology. CMS hopes that by aligning quality metrics, it will reduce the reporting burden.

Supervision. CMS is proposing to lessen the requirements under 42 C.F.R. § 410.74(a)(2) related to physician supervision of PAs. Under the proposal—in the absence of a state law provision to the contrary—physician supervision for PA services, under Medicare, would be evidenced by documentation in the medical record of the "PA’s approach to working with physicians in furnishing their services." The change would align the PA supervision requirements with the current requirements for Nurse Practitioners and Certified Nurse Practitioners.

Medical records. The proposed rule contains a provision which would allow physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives to review and verify (sign and date) notes made in the medical record by other members of the medical team. This would relieve those practitioners of the need to document the same information a second time.

Opioid treatment programs. The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT Act) established a new Medicare Part B benefit for opioid use disorder (OUD) treatment services furnished by opioid treatment programs (OTPs). The proposed rule addresses this by proposing to define OUD and OTP treatment services, set enrollment policies for OTPs, estimating bundled payment rates for OPTs, allowing counseling and therapy for these services to be provided via audio-video communication technology, and eliminating beneficiary co-payments for these services for a limited time.

Telehealth. CMS is proposing to add three HCPCS codes—GYYY1, GYYY2, and GYYY3—to the list of telehealth services. The proposed codes describe a bundled episode of care for treatment of opioid use disorders.

Ambulance. CMS is proposing the data collection format and sampling methodology it will use to establish an ambulance data collection system. The Bipartisan Budget Act (BBA) of 2018 requires HHS to establish the collection system to gather cost, revenue, utilization, and other information pertaining to ground ambulance provider organizations. CMS is proposing to reduce a ground ambulance organization’s payments by 10 percent if that organization fails to sufficiently submit data under the program.

Stark. CMS is also accepting comments regarding the advisory opinion process on physician referrals. The agency hopes to develop a way to both reduce provider burden and uncertainty around Stark Law compliance.

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