On November 1, CMS issued a final rule that includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) effective on or after January 1, 2020.

Payment Provisions:

• Ratesetting and conversion factor  CMS is finalizing 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.
• Medicare telehealth services CMS is adding the following codes to the list of telehealth services: HCPCS codes G2086, G2087, G2088, which describe a bundled episode of care for treatment of opioid use disorders.
• Evaluation and management services The CPT coding changes retain 5 levels of coding for established patients, reduce the number of levels to 4 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 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.   Also, CMS is adopting 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.
• Physician supervision requirements for physician assistants 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.
• Review and verification of medical record documentation CMS is finalizing broad modifications to the documentation policy so that physicians, physician assistants, and advanced practice registered nurses (APRNs – nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists) can review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, medical, physician assistant, and APRN students, nurses, or other members of the medical team.
• Care management servicesFor CY 2020, we are finalizing our proposal to increasing payment for transitional care management (TCM) services which are care management services provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays.

  We are creating a Medicare-specific code for additional time spent beyond the initial 20 minutes allowed in the current coding for chronic care management (CCM) services, which are services provided to beneficiaries with multiple chronic conditions over a calendar month.

  Recognizing that clinicians across all specialties manage the care of beneficiaries with chronic conditions, we are also creating new coding for principal care management (PCM) services, for patients with only a single serious and high-risk chronic condition.

• Medicare coverage for opioid use disorder treatment services furnished by opioid treatment programs CMS is finalizing the definition of OUD treatment services which includes:
  • FDA-approved opioid agonist and antagonist treatment medications,
  • The dispensing and administering of such medications (if applicable),
  • Substance use counseling,
  • Individual and group therapy,
  • Toxicology testing which includes both presumptive and definitive testing,
  • Intake activities, and
  • Periodic assessments.
• Bundled payments under the PFS for opioid use disorders  A bundled payment for the management and counseling for OUD, will create an avenue for clinicians to bill for a group of services in the office setting similar to the services being paid for under the new OTP benefit for opioid treatment program clinics. CMS is finalizing the creation of new coding and payment for a monthly bundle of services for the treatment of OUD that includes overall management, care coordination, individual and group psychotherapy, and substance use counseling, as well as an add-on code for additional counseling. The individual psychotherapy, group psychotherapy, and substance use counseling included in these codes could be furnished as Medicare telehealth services using communication technology as clinically appropriate.
• Therapy services CMS established modifiers to identify therapy services that are furnished in whole or in part by physical therapy (PT) and occupational therapy (OT) assistants, and set a de minimis 10 percent standard for when these modifiers will apply to specific services.

Other Provisions:

• Quality Payment Program
• Ambulance services
• Ground ambulance data collection system
• Open Payments Program
• Medicare Shared Savings Program

This rule will be published in the Federal Register for November 15, 2019.

CMS has issued a news release on this topic.