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7 Important Facts to be Aware of for the PFS Proposed Rule

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule they believe will ensure clinicians spend more time providing high-value care for patients instead of filing cumbersome paperwork. The proposals are included in CMS's annual changes to the Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP).

The 7 important facts from the calendar year (CY) 2020 PFS proposed rule:

1. PFS rate and conversion factor would go up slightly in CY 2020 to $36.09. In CY 2019. The PFS conversion factor was $36.04.

2. CMS is proposing to add the following codes to the list of telehealth services: HCPCS codes GYYY1, GYYY2, and GYYY3, which describe a bundled episode of care for treatment of opioid use disorders.

3. Changes to payment for Evaluation and Management (E/M) services. CMS said they are proposing to align E/M coding with changes suggested by the CPT Editorial Panel for office/outpatient E/M visits:

  • Retain 5 levels of coding for established patients.
  • Reduce the number of levels to 4 for office/outpatient E/M visits for new patients.
  • Revise code definitions.
  • Revise times and medical decision-making process for all codes.
  • Require performance of history and exam only as medically appropriate.
  • Allow clinicians to choose the E/M visit level based on either medical decision making or time.

CMS is proposing to adopt the AMA 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 valued would increase payment for office/outpatient E/M visits.

Additionally, CMS is proposing to consolidate the Medicare-specific add-on code for office/outpatient E/M visits for primary care and non-procedural specialty care that was finalized in the CY 2019 PFS final rule for implementation in CY 2021 into a single 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.

4. Modification of physician supervision for physician assistants (PAs). In the absences of State law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA's approach to working with physicians in furnishing their services.

5. CMS is proposing to modify the documentation policy so that physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives could review and verify (sign and date), rather than re-documenting notes made in the medical record by other physicians, residents, nurses, students, or other members of the medical team.

6. Medicare coverage for opioid use disorder services furnished by opioid treatment programs (OTPs). Specifically, CMS is proposing:

  • Definitions of OTP and opioid use disorder (OUD) treatment services;
  • Enrollment policies for OTPs;
  • Methodology and estimated bundled payment rates for OTPs that vary by the medication used to treat OUD and service intensity, and by full and partial weeks;
  • Adjustments to the bundled payments rates for geography and annual updates;
  • Flexibility to deliver the counseling and therapy services described in the bundled payments via two-way interactive audio-video communication technology as clinically appropriate; and
  • Zero beneficiary copayment for a time limited duration.

This will be implemented by January 1, 2020, as required by the SUPPORT Act.

7. Beginning January 1, 2020 modifiers to identify therapy services that are furnished in whole or in part by physical therapy (PT) and occupational therapy (OT) assistants, and the de minimis 10 percent standard for when these modifiers will apply to specific services will be implemented.

To read the rest of the proposed changes and requests for comment click HERE.

CMS is asking for public comments to be provided no later than September 27, 2019.

Healthcare Compliance Pros will be watching closely for additional guidance, comments, and opinions regarding the CY 2020, PFS proposed changes.

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