• Fee Schedule Summary: AAFP Advice Visible in CMS Final Rule

    Outpatient Prospective Payment System Final Rule Also Released

    November 12, 2019 03:36 pm News Staff – The AAFP recently released a summary of the final 2020 Medicare physician fee schedule(3 page PDF) that emphasizes a significant change on the horizon: a payment boost stemming from ongoing Academy advocacy.

    Specifically, the combined final rule and interim final rule CMS issued Nov. 1 calls for higher payments for evaluation and management codes and the development of primary care add-on codes, resulting in a 12% increase in total allowed charges for family physicians starting in 2021.

    The final 2020 MPFS conversion factor is $36.0896 (2019's was $36.0391), resulting in no change in total Medicare allowed charges for family medicine in 2020.

    Evaluation and Management Services

    The Academy had long advised CMS that undervaluation of E/M services slowed crucial investments in primary care. As supported by the AAFP, the final rule aligns E/M coding with changes laid out by the CPT Editorial Panel for office and outpatient E/M visits, starting in 2021. This means that

    • five levels of coding will be retained for established patients;
    • the number of levels will be reduced to four for office and outpatient E/M visits for new patients;
    • the times and medical decision-making process for all office-based E/M codes will be revised, and performance of history and exam will be required only as medically appropriate; and
    • clinicians will be able to choose the E/M visit level based on either medical decision-making or time.

    CMS finalized the adoption of Academy-supported, AMA/Specialty Society Relative Value Scale Update Committee-recommended values for the office and outpatient E/M visit codes for 2021, as well as a new add-on CPT code for prolonged service time, which CMS outlined in a fact sheet also released on Nov. 1.


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    Quality Payment Program

    As outlined in a CMS executive summary of the 2020 Quality Payment Program the Merit-based Incentive Payment System will operate with the following performance thresholds and category weights for the 2020 performance period (which equates to the 2022 payment year):

    • performance threshold: 45 points,
    • additional performance threshold for exceptional performance: 85 points,
    • quality performance category weight: 45%,
    • cost performance category weight: 15%,
    • promoting interoperability performance category weight: 25% and
    • improvement activities performance category weight: 15%.

    For the 2021 performance period, however, CMS has raised the performance threshold to 60 points, with the additional performance threshold for exceptional performance remaining at 85 points.

    Coverage for Opioid Treatment Program

    In a move the Academy backed, the 2020 MPFS establishes Medicare coverage for medication-assisted treatment for opioid use disorder.

    CMS finalized the creation of new coding and payment for a monthly bundle of services for 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.

    Outpatient Prospective Payment System

    Also on Nov. 1, CMS also issued "Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs" as a final rule with comment period.  

    The Academy had encouraged CMS in a Sept. 19 letter(2 page PDF) to consider site-of-service payment parity from a broader perspective and to create incentives for services to be performed in the most cost-effective location, such as a physician's office.

    The final rule includes a policy that continues to eliminate differential payments between certain outpatient sites of service, completing a two-year phase-in of the move to reduce unnecessary utilization in outpatient services by addressing payments for clinic visits furnished in the off-campus hospital outpatient setting. This could save Medicare beneficiaries $160 million and the Medicare program $650 million in 2020.

    However, CMS did not finalize an Academy-backed proposal to require hospitals to disclose prices for all supplies, tests and procedures. A separate final rule on the issue is expected in the future, the agency said.

    Related AAFP News Coverage
    AAFP Offers CMS Improvements to Proposed 2020 MPFS

    Academy Takes First Look at Proposed Rule for 2020 MPFS