The Centers for Medicare & Medicaid Services (CMS) has issued its final rule updating the Medicare physician fee schedule (PFS), quality payment program, and other Medicare Part B payment policies for calendar year (CY) 2020. The final rule is effective Jan. 1.
Key provisions of the final rule are highlighted below:
- Evaluation and management (E/M) services: In a change from its policies finalized for the CY 2019 PFS, CMS now has separate payment rates for all levels of E/M visits, rather than blending payment rates for certain levels. Specifically, CMS retains five levels of coding for established patients, reduces the number of levels to four for new patients, and allows providers to choose the E/M level based on either medical decision-making or time. In addition, beginning with CY 2021, CMS will adopt a single add-on code for prolonged service time, consolidating previously finalized add-on codes for primary care and non-procedural specialty care.
- Medicare coverage for opioid use disorder treatment service: CMS has adopted policies implementing requirements of the SUPPORT Act to establish a new Medicare Part B benefit for opioid use disorder (OUD) treatment services – including medications for medication-assisted treatment – furnished by opioid treatment programs.
- Bundled payments for substance use disorder services: CMS has established new coding and payment for a bundled episode of care for management and counseling for OUD under the PFS. The codes describe a monthly bundle of services for the treatment of OUD that includes overall management, care coordination, individual and group psychotherapy, and substance use counseling.
- Telehealth services: CMS is adding three Healthcare Common Procedure Coding System codes related to the new bundled episode of care for treatment of OUD to the list of available telehealth services. Specifically, the individual psychotherapy, group psychotherapy, and substance use counseling included in these bundled payment codes can be furnished as Medicare telehealth services using communication technology, as clinically appropriate.
- Case management services: CMS has adopted several policies related to case management services, including increasing payment and billing flexibility for case management provided to beneficiaries after discharge from inpatient and certain outpatient stays. CMS also has finalized a new Medicare-specific code for additional time spent beyond the initial 20 minutes allowed in the current coding for chronic care management services, and has established a new code for principal care management services for patients with a single serious and high-risk chronic condition.
- Therapy services: CMS is implementing policies related to new mandated therapy modifiers — finalized in the CY 2019 PFS final rule — to identify therapy services furnished in whole or in part by physical therapy and occupational therapy assistants. Beginning with services furnished in 2022, these services are paid at a reduced level; CMS clarifies that this does not apply to services furnished by critical access hospitals because they are not paid for therapy services at PFS rates.
- Medicare Shared Savings Program: CMS has made changes to the Medicare Shared Savings Program quality reporting requirements, by reverting two measures to pay-for-reporting for a limited time due to substantive changes to the measure specifications.
- Quality Payment Program: CMS has finalized changes to the physician Quality Payment Program, including updates to the Merit-based Incentive Payment System (MIPS) for the CY 2020 reporting period, such as higher performance standards for earning positive payment adjustments. Notably, CMS did not finalizes its proposal to increase the weight of the MIPS cost category. CMS has also finalized policies related to incentives for alternative payment model participation.