CMS Medicare Physician Fee Schedule Final Rule Increases Value for Minimally Invasive SI Joint Spine Fusion
November 30, 2019
ISASS, Other Stakeholders Respond to the White House’s Executive Order on Medicare
November 30, 2019

In addition to the proposed RVU changes for CPT 27279, the 2020 Medicare Physician Fee Rule updated several policies of relevance to ISASS members.

Payment is made under the Physician Fee Schedule (PFS) for services furnished by physicians and other practitioners in all sites of service. These services include, but are not limited to, office visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services.

In addition to physicians, payment is made under the PFS to a variety of practitioners and entities, including nurse practitioners, physician assistants, and physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities.

Payments are based on the relative resources typically used to furnish the service. Relative value units (RVUs) are applied to each service for physician work, practice expense, and malpractice. These RVUs become payment rates through the application of a conversion factor. Payment rates are calculated to include an overall payment update specified by statute.

PAYMENT PROVISIONS

CY 2020 PFS Rate-setting and Conversion Factor

In the final rule, CMS finalized a series of standard technical proposals involving practice expense, including the implementation of the second year of the market-based supply and equipment pricing update, and standard rate setting refinements to update premium data involving malpractice expense and geographic practice cost indices (GPCIs).

With the budget neutrality adjustment to account for changes in RVUs, as required by law, the finalized CY 2020 PFS conversion factor is $36.09, a slight increase of $0.05 above the CY 2019 PFS conversion factor of $36.04.

Evaluation and Management (E/M) Services
In the final rule, CMS accepted changes adopted by the American Medical Association (AMA) Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits. The CPT coding changes retain five levels of coding for established patients, reduce the number of levels to four for office/outpatient E/M visits for new patients, and revise the code definitions. The CPT code changes also revise the times and medical-decision-making (MDM) process for all of the codes and requires performance of history and exam only as medically appropriate. The CPT code changes also allow clinicians to choose the E/M visit level based on either medical decision-making or time.

As CMS proposed in the July 2019 Proposed Rule, the final rule announced the adoption of the AMA Specialty Society Relative Value Scale Update Committee (RUC) recommended values for the office/outpatient E/M visit codes for CY 2021 and the new add-on CPT code for prolonged service time. The AMA RUC-recommended values will increase payment for office/outpatient E/M visits. The RUC recommendations reflect a robust survey approach by the AMA, including surveying more than 50 specialty types, and demonstrating that office/outpatient E/M visits are generally more complex and require additional resources for most clinicians. CMS also proposed adding a single add-on code describing the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. This will also be implemented in CY 2021.

Finally, and most important for ISASS members, CMS stated at this time, they are not adopting changes to the global surgery codes, as they continue to evaluate data. ISASS, along with other surgical specialties, had written strong comments to CMS urging adoption of the changes to global surgery codes, and ISASS will continue to advocate for these changes to global surgery codes.

Other issues covered in the final rule were updated regulation on physician supervision of PAs to give PAs greater flexibility to practice more broadly in the current health care system in accordance with state law and state scope of practice. In the absence of any state rules, CMS is finalizing a revision to the current supervision requirement to clarify that physician supervision is a process in which a PA has a working relationship with one or more physicians to supervise the delivery of their health care services. Such physician supervision is evidenced by documenting the PA’s scope of practice and indicating the working relationship(s) the PA has with the supervising physician(s) when furnishing professional services.

Section 2005 of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) established a new Medicare Part B benefit for opioid use disorder (OUD) treatment services, including medications for medication-assisted treatment (MAT), furnished by opioid treatment programs (OTPs). CMS is implementing this benefit beginning Jan. 1, 2020, as required by the SUPPORT Act.

Open Payments Program
CMS’s Open Payments Program promotes a transparent and accountable healthcare system by annually publishing the financial relationships that physicians and teaching hospitals (known as “covered recipients”) have with applicable manufacturers and group purchasing organizations (GPOs). CMS continues to make adjustments to the program to reflect new statutory requirements and stakeholder feedback. Therefore, CMS is proposing several changes to Open Payments: 1) expanding the definition of “covered recipient;” (as required by the SUPPORT Act) 2); modifying payment categories; and 3) standardizing data on reported medical devices.

Read the CMS Fact Sheet on the Final Rule here.

Read the Final Rule here.