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CMS Medicare Fee-For-Service FY 2020 Proposed Rules Part 2: Physician Fee Schedule and Home Health

This week, our In Focus section reviews the new Centers for Medicare & Medicaid Services (CMS) Medicare Fee-For-Service FY 2020 proposed rules: the Physician Fee Schedule (PFS), released on July 2019, and Home Health prospective payment system, released on July 11, 2019. For the hospital outpatient department (HOPD) and ambulatory surgical center (ASC) prospective payment systems (PPS) and the End-Stage Renal Disease (ESRD) PPS proposed rules, please see last week’s In Focus here.

2020 Physician Fee Schedule (PFS) Proposed Rule Highlights

PFS payment and coding provisions

CMS proposed a slight increase of less than 0.5 percent to overall PFS payment rates by raising the PFS conversion factor to $36.09 in CY 2020, up from $36.04 in CY 2019. CMS‘s proposals also include new PFS codes which provides reimbursement for new services for beneficiaries and as well as provisions to reduce the clinicians’ burden. Specifically, CMS proposed to:

  • Reduce the number of levels of evaluation and management (E&M) codes for new patients from five to four, while retaining the five-tier system for established patients. As a part of this, CMS also proposed to revise the standard of time required to treat patients at each code level and the medical decision making process for these E&M codes to enable clinicians to choose the E&M level based on either time or medical decision making, as opposed to only time.
  • Increase payment for the Transitional Care Management (TCM) service code, which accounts for care management services provided to beneficiaries following inpatient discharge.
  • Create additional codes as a part of the Chronic Care Management (CCM) service to enable clinicians to bill separately for patients requiring more time or resources.
  • Create a new care management code for Principal Care Management (PCM) services. This code would pay clinicians for providing care management for patients with high risk conditions.
  • Add three new telehealth codes to the list of permitted telehealth services, each of which provide for a bundled episode of care for treatment in opioid use disorders.

Opioid use disorder (OUD) treatment services

To meet the statutory requirements of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act, CMS proposed the establishment of a new Medicare Part B benefit for opioid use disorder treatment services. OUD services include: opioid agonist and antagonist treatment medications approved by the Food and Drug Administration (buprenorphine, methadone, and naltrexone), the administration of these medications, substance use counseling, individual and group therapy with a physician or psychologist, toxicology testing. This also includes medication-assisted treatment (MAT) furnished by opioid treatment programs (OTP), which Medicare has not previously covered. These new services are proposed for implementation January 1, 2020. To bill Medicare for these services, OTPs must be enrolled in Medicare, and must have current accreditation with SAMHSA to provide a wide range of OUD services.

CMS proposes to pay OTPs a bundled rate for OUD services but seeks input on the various aspects of how the bundle should be designed. CMS proposed the OUD bundle will be a 7-day episode bundle, and OTPs would be permitted to bill for partial episode payment if the patient does not complete the full episode. CMS proposes to develop different OUD bundles depending upon the level of drug therapy used for treatment. Telehealth will be permitted and add-on payments for extra therapy sessions will be provided. Payment for these services would not rely on PFS relative value units because these services will fall outside of the PFS. CMS is considering several methodologies for pricing the OUD payment bundles.

Bundled payment policies

CMS continues to focus on the development of bundled payment models. In the 2020 PFS proposed rule, CMS proposed to create a bundled payment for the of care for opioid use disorder (OUD). The proposed OUD bundled payment would provide a monthly episode payment to the clinician for overall care management, care coordination, individual and group psychotherapy, and substance use counseling. CMS proposed separate codes for 1) the initial month of service, 2) subsequent months of treatment, and 3) add-on counseling services. As a part of the bundled payment, services could be provided via telehealth.

CMS is also soliciting comment on two other bundled payment issues. First, CMS solicited comments on bundled payment for other substance use disorders and for the use of medication assisted treatment in the emergency department setting. Second, CMS solicited comments on new bundled payment model concepts that could be implemented within the PFS.

Clinician reporting and documentation requirements

CMS proposed several changes designed to reduce clinicians’ administrative documentation requirements. Notably, CMS proposed modifying the physician supervision requirement for physician assistants (PA) to create greater flexibility for clinicians by permitting PAs to document in the medical record that they had been working with physicians to furnish services rather than requiring physician documentation. In addition, CMS proposed that clinicians of all types will no longer be required to re-document notes in the medical record in order to be in compliance with documentation requirements. Instead, clinicians will be permitted to review and verify information in the patient medical record.

Merit-based Incentive Payment System (MIPS) Value Pathways and Medicare Shared Savings Program (MSSP)

CMS proposed to reduce physician quality data reporting requirements under MIPS beginning in 2021. Under the current MIPS system, clinicians are required to report on many measures across the multiple performance categories, such as Quality, Cost, Promoting Interoperability and Improvement Activities. Under the new MIPS Value Pathways program, clinicians would report on a smaller set of measures that are specialty-specific, outcome-based, and more closely aligned to Alternative Payment Models (APMs). The new program is meant to connect activities and measures from the four existing MIPS performance categories that are relevant to the population clinicians are treating.

CMS solicits comment on how to better align the quality performance scoring methodology of the Medicare Shared Savings Program (MSSP) more closely with the MIPS quality performance scoring methodology. In addition, CMS proposed making slight modifications to the MSSP quality measure set.

Therapy Services

Beginning in January 2020, claim modifiers identifying the use of physical therapy assistants or occupational therapy assistants for therapy services will be required. In addition, CMS proposed to implement a 10 percent minimum standard to claims involving therapy assistants. On claims where 10 or more percent of the service is attributable to the therapy assistant, payment will be made according to the therapy assistants’ rate, not the non-assistant therapist.

Ambulance payment policy

CMS proposed revisions to the Physician Certification Statement requirements ambulance suppliers and providers are subject to in order to justify ambulance transport. CMS acknowledged that it will accept other forms of PCS documentation when formal signatures cannot be obtained. In addition, CMS proposed to expand the list of non-physician clinicians who may certify transport of a patient when a signed PCS cannot be obtained. The list was expanded to include licensed practical nurses, social workers, and case managers.

CMS proposed the various data collection format and elements to collect cost reports from ambulance providers and suppliers from 2020 through 2024. For 2020, the agency proposes to collect a stratified random sample of 25 percent of the ambulance industry. CMS proposed to stratify the sample based on characteristics such as location (urban, rural, and super-rural) ownership status (for-profit, non-profit, government), and Medicare transport volume. This sampling effort will be in place for four years. After 2024, CMS will require cost reports from one-third of the industry annually. Beginning in 2022, sampled ambulance providers and suppliers failing to submit cost data will have their payments for individual transports reduced 10 percent.

 2020 Medicare Home Health Proposed Rule Highlights

Home Health payment provisions

CMS proposed to update home health payment rates by 1.5 percent in FY 2020. This increase is smaller than the increase made to 2019; a 2.2 percent increase was implemented in CY 2019. On net, this will result in an increase in payments to home health providers of $250 million (1.3 percent net increase).  The rate update for CY 2020 includes adjustments for anticipated changes related to implementation of the Patient-Driven Groupings Model (PDGM), which will revise the home health payment model from 60-day episodes based on the number of therapy visits to 30-day periods of care based on patient characteristics. CMS also proposed a behavioral-based payment reduction of 8 percent to offset anticipated increases in overall spending that result from changes in coding and diagnosis practices after the model is implemented. CMS also proposes the use of updated wage index data for the home health wage index, and updates to the fixed-dollar loss ratio to determine outlier payments.

CMS seeks comments on the wage index used to adjust home health payments and suggestions for possible updates and improvements to the geographic adjustment of home health payments.

Proposed Payment Rate Changes for Home Infusion Therapy Temporary Transitional Payments and New Home Infusion Therapy Benefit for CY 2021

Under the proposed rule, CMS would make routine updates to the home infusion therapy payment rates for CY 2020 and would implement a permanent home infusion therapy benefit beginning in CY 2021. CMS is proposing to group infusion drugs into three payment categories, with each category having an associated single unit of payment in accordance with the Physician Fee Schedule and weighted based on geographic practice cost indices. CMS would set higher payment amounts for a beneficiary’s first home infusion therapy visit, with lower amounts for each subsequent visit.

Regulatory Burden Reduction and Program Integrity Changes

In an effort to reduce administrative burden and potential program integrity risks, CMS proposes to phase out Requests for Anticipated Payment (RAP), which enable home health agencies to receive payments at the beginning of episodes of care based on the total estimated cost of services. CMS would reduce the RAP split-percentage payment for existing home health agencies in CY 2020 and eliminate split-percentage payments for all home health agencies in CY 2021.

Paraprofessional Roles – Improving Access to Care

CMS proposes to modify current regulations to allow therapist assistants, in addition to therapists, to perform maintenance therapy under the Medicare home health benefit in accordance with individual state practice requirements, allowing therapist assistants to practice at the top of their licensure and providing home health agencies with flexibility to meet their patients’ maintenance therapy needs.

Home Health Value-Based Purchasing (HHVBP) Model

To support the ability to compare home health agency quality, CMS is proposing to publicly report HHVBP Model performance data including the Total Performance Score (TPS) and the TPS Percentile Ranking for each home health agency in the nine Model states that qualified for a payment adjustment for 2020. CMS expects that these data would be made public after December 1, 2021, after CMS issues the final CY 2020 Annual Report to each home health agency.

Home Health Quality Reporting Program (HH QRP)

Under the HH QRP, CMS publicly reports on quality measure and standardized patient assessment data submitted by home health agencies. CMS is proposing to remove one HH QRP measure, adopt two new measures to improve the transfer of health information and interoperability, modify an existing measure, adopt new standardized patient assessment data beginning with the CY 2022 HH QRP, codify the HH QRP policies in a new section, and remove a question from all the HH Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys.

Specifically, CMS is proposing to eliminate the Pain Interfering with Activity Measure to “mitigate any potential unintended, over-prescription of opioid medications inadvertently driven by these measures.” CMS is also proposing to adopt several standardized patient assessment data elements designed to assess cognitive function and mental status, special services, treatments and interventions, medical conditions and comorbidities, impairments, and social determinants of health.

HMA continues to analyze these proposed rules and will provide more detailed analyses evaluating the impacts of key CMS Part B proposals in the coming weeks. For more information or questions about these proposed Part B rules and HMA’s Medicare Practice, please contact Mary Hsieh or Jon Blum.

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