After weeks of reviewing CMS' proposed 2020 Medicare physician fee schedule,(www.govinfo.gov) the AAFP has fired off a 61-page comment letter(61 page PDF) outlining items that will make good policy and, more importantly, pinpointing areas that need revision.
The Sept. 18 letter to CMS Administrator Seema Verma, M.P.H., was signed by AAFP Board Chair Michael Munger, M.D., of Overland Park, Kan.
"The recommendations we offer in this letter reflect our members' experiences caring for patients across the country and our goal to build a health system founded in family medicine and primary care that improves health and reduces system costs," noted the AAFP.
"More than 90% of family physicians accept Medicare -- making them the foundation of care delivery for our health system," said the letter.
- The AAFP recently responded to CMS' proposed 2020 Medicare physician fee schedule with a detailed letter to CMS Administrator Seema Verma, M.P.H.
- The letter briefly described a few high-profile issues that greatly impact family physicians before making in-depth comments.
- Among other things, the AAFP discussed evaluation and management coding, global surgical packages, chronic care management, and advanced alternative payment models.
The AAFP began with its own version of a highlights reel, using bullet points to outline high-profile issues that impact family physicians daily, such as evaluation and management coding, chronic care management, and payment issues related to the Merit-based Incentive Payment system and advanced alternative payment models.
Family physicians interested in the intricate details of the AAFP's comments are invited to take time to read the letter in its entirety. For those who want an overview, here's a quick look at key topics.
E/M Coding Revaluation
The AAFP registered its appreciation and strong support for CMS' proposal to accept recommendations from the AMA/Specialty Society Relative Value Scale Update Committee to adopt work relative value units for all office and outpatient E/M codes and the prolonged services add-on code.
But the AAFP raised a red flag regarding the timing of implementation, with the proposal slated to go into effect for services dated on or after Jan. 1, 2021. The Academy argued instead for an almost immediate start date.
"Since most family medicine practices already operate on extremely thin margins, and these services have been undervalued for decades, we implore CMS to implement these changes in 2020," said the letter.
The AAFP also commended CMS for dropping a previous proposal that would have implemented a blended payment rate for E/M levels two through four.
Global Surgical Packages
In the proposed rule, CMS said it needed more time to study the issue of work RVUs for procedures with a global period and pointed to research from RAND Corp. that could prove useful; the AAFP supported this approach.
"Until such time that verifiable, third-party data provides a clearer justification for the inclusion of E/M codes in the global period, we strongly support CMS' decisions as outlined in the proposed rule," said the AAFP.
The letter pointed out that the Office of the Inspector General and others "have questioned the accuracy of current assumptions underlying 10- and 90-day global codes."
The AAFP suggested that the best approach would be to convert all codes with a 10- or 90-day global period to zero-day global periods and have physicians code and document pre- and postoperative services using E/M codes.
Furthermore, the letter noted, "for decades, physicians using these global codes have not been required to follow the E/M documentation guidelines for charting in the medical record for such visits, which has been blatantly unfair to the rest of the physician community and especially primary care."
The AAFP called for elimination of the global service codes and a leveling of the playing field for all physicians.
Chronic Care Management
With regard to coding and payment for chronic care management services, the AAFP voiced concern about the addition of new codes -- referred to as principal care management codes -- because of the negative effect those codes could have on patient care.
Specifically, the Academy pointed out that implementation of PCM codes could lead to patients with multiple chronic conditions having their care managed by multiple clinicians, each of them billing only for PCM, "which could result in fragmented patient care, and overlapping and duplicative services."
The AAFP therefore opposes the proposed PCM codes.
"Allowing PCM to be reported for such patients either in addition to, or instead of, complex chronic care management is an invitation to linger in FFS (fee for service) and moves away from the continuous, comprehensive and coordinated value-based and primary care that CMS has otherwise been encouraging as a cost-effective way to care for Medicare patients," said the AAFP.
The Academy told CMS that if the agency proceeds with its proposal to create new codes despite these concerns, then the AAFP would support CMS' plan to allow primary care physicians to bill for PCM services if a beneficiary has any complex chronic condition overseen by that physician.
Lastly, the AAFP agreed with CMS that an initiating visit and verbal consent should be required for PCM services, just as they are for chronic care management services.
"From our perspective, PCM services are no different than CCM services except in the total number of chronic conditions the patient has," said the AAFP.
Both the AAFP and CMS recognized a potential gap in coding and payment for care management services for patients with just one chronic condition, and the letter encouraged CMS to work through the CPT process for a solution rather than create its own codes.
MIPS Value Pathways
In the proposed rule, CMS suggested a new Merit-based Incentive Payment Program "value pathway" that, in theory, would streamline the physician reporting experience.
The AAFP acknowledged CMS' awareness of the complexity of MIPS and its willingness to improve the program.
"However, we note that while the MVP (MIPS value pathway) structure may reduce burden related to selection of measures, it does not necessarily reduce the overall burden of the program," said the AAFP. "We believe CMS could further reduce reporting burden by incorporating multi-category credit into the MIPS and/or MVP structure."
The Academy also told CMS that the complexity of the MIPS program is not the biggest barrier physicians face when it comes to participating in an alternative payment model; rather, it's the scarcity of APMs.
Another issue for small practices is their inability to handle the financial risk of an advanced APM. "A restructured MIPS program could better prepare these practices for the transition to an APM," the AAFP said in its letter.
The Academy urged CMS to "carefully consider the impact of MVPs on practices" and made suggestions on how to best move forward. For instance, the AAFP noted that the wide scope of family medicine would be difficult to condense into a singe MIPS value pathway.
"We caution CMS against creating a single MVP per specialty," said the AAFP. Rather, CMS should consider the difference in practice types and specialties and "create a sufficient number of MVPs to meet the diverse needs of practices."
The AAFP also strongly recommended that CMS "maintain equitable reporting requirements across all specialties; such fairness is essential in furthering the agency's support of family medicine and primary care."
The AAFP noted there was much work to be done before MIPS value pathways could be implemented and urged CMS to refrain from implementing them in the 2021 MIPS performance period as proposed.
The AAFP noted its continued concern about the impact of MIPS APMS on physicians in small practice settings.
"The APM scoring standard is applied, for the most part, to large practices," said the AAFP. "This preferential scoring has given large practices a scoring advantage in MIPS and has disadvantaged small/solo practices."
The AAFP also reasoned that physicians are being held back from moving from MIPS to APMs by "lack of program availability, uncertain program stability and primary care payments that do not support APM participation."
CMS' recent announcement about its Primary Care First initiative also warranted a note that the AAFP is "cautiously optimistic" about the initiative's potential to strengthen patient access to comprehensive primary care.
The Academy called for more advanced APM options and also took advantage of the opportunity to remind CMS that the AAFP submitted its own Advanced Primary Care Alternative Payment Model,(38 page PDF) which the Physician-Focused Payment Model Technical Advisory Committee recommended for testing in December 2017.
"We continue to advocate for improvements to the model and encourage CMS to implement the AAFP's APC-APM proposal," said the letter.
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