The Centers for Medicare and Medicaid Services (CMS) is seeking to change its approach to paying clinicians for many office visits, incorporating recommendations and ideas from research done by the American Medical Association. Medicare also is pressing for greater disclosure to consumers about hospital prices and for the creation of incentives for dialysis centers to adopt newer technologies. CMS announced these plans as it unveiled three draft payment rules for 2020.
By increasing the value of E/M codes for office/outpatient visits and providing enhanced payments for certain types of visits. CMS trying to invest in the critical thinking required to evaluate a patient, which will help improve outcomes. About 1 in 5 people enrolled in Medicare have multiple chronic diseases.
Proposed Coding Changes Align With AMA Guidance
In a fact sheet on the proposed rule, CMS said it intends to align its E/M coding with changes laid out by the American Medical Association (AMA)’s CPT Editorial Panel for office/outpatient E/M visits. The CPT coding changes maintain five levels of coding for established patients and cut the number of levels to four for office/outpatient E/M visits for new patients.
The changes for CPT also change the medical decision-making process for the codes, while requiring the performance of history and exam only as medically appropriate. CPT code changes also allow clinicians to choose the E/M visit level based on either medical decision-making or time involved. CMS also intends to incorporate work done by the AMA’s Relative Value Scale Update Committee (RUC). The AMA RUC-recommended values would increase payment for office/outpatient E/M visits.
The physician fee rule also covers nurse practitioners, physician assistants (PAs), and physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities. In the fact sheet, CMS said it is seeking through the rule to modify the regulation of PAs. The agency intends to give PAs “greater flexibility to practice more broadly in the current health care system in accordance with state law and state scope of practice.”
2020 Quality Payment Program Performance Period
- Increase in the performance threshold from 30 points in 2019 to 45 points in 2020, and 60 points in 2021.
- Additional increase for exceptional performance to 80 points in 2020 and to 85 points in 2021.
- Revision of the performance category weights for Quality to 40 percent in 2020, 35 percent in 2021, and 30 percent in 2022 performance year.
- Increase in Cost performance category for Cost to 20 percent in 2020, 25 percent in 2021, and 30 percent in 2022 performance year.
- Revision of the specifications for the Total Per Capita Cost and Medicare Spending Per Beneficiary Clinician measures (adding 10 new episode-based measures).
- Maintaining Promoting Interoperability and Improvement Activities at 25 percent and 15 percent, respectively.
- Maintaining performance-based scoring on individual measures under Promoting Interoperability performance category.
- Increase in the data completeness threshold for the quality data that clinicians submit.
- Increase in the threshold for clinicians who complete or participate in the Improvement Activity for group reporting.
- Updates to requirements for Qualified Clinical Data Registry (QCDR) measures and the services that third-party intermediaries must provide (beginning with the 2021 performance period).
- Application of a new Merit-Based Incentive Payment System (MIPS) Value Pathways (MVPs) framework to future proposals beginning with the 2021 MIPS Performance Year. MVPs would utilize sets of 106 measures and activities that incorporate a foundation of promoting interoperability and administrative claims-based population health measures and layered with specialty/condition-specific clinical quality measures to create both more uniformity and simplicity in measure reporting.
- Maintaining the low-volume threshold, eligible clinician types, MIPS performance periods, CEHRT requirements, and small practice bonus points.
In a separate proposed rule covering Medicare’s 2020 payment for outpatient services provided at hospitals, CMS put forward what the agency called “historic changes” regarding cost disclosures. CMS said hospitals will need to make public their “standard charges,” which the agency defines as two types of charges: gross charges and payer-specific negotiated charges. CMS also said hospitals will need to post information on standard charges online in a machine-readable file.
And CMS also released a draft rule covering Medicare’s 2020 payments for care of people enrolled in the program who have an end-stage renal disease (ESRD). This proposal would alter the approach to deciding which products qualify for the transitional drug add-on payment adjustment (TDAPA) under the ESRD payment rule. The aim is to better target the additional payments to “innovative renal dialysis drugs and biological products,” with CMS proposing to exclude generic drugs from TDAPA eligibility.
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