On July 29, 2019, the Centers for Medicare & Medicaid Services (CMS) released its much-anticipated proposed rule: CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies [CMS-1715-P]. The 1,704-page rule includes proposals that impact both the Medicare Physician Fee Schedule (MPFS) and the Quality Payment Program (QPP). ASA leaders and staff have already started a thorough review of the rule and will continue to post updates to keep ASA members informed.
Fee Schedule Issues:
Conversion Factor Updates: There are no MACRA-related adjustments to the conversion factor until 2026 but a positive budget neutrality adjustment is predicted. If all provisions within the rule are accepted as proposed, the Medicare Anesthesia Conversion Factor will increase from $22.2730 to $22.2774 and the conversion factor used to calculate payments for services paid via the Resource Based Relative Value System (RBRVS) will rise from $36.0391 to $36.0896.
Code Level Changes: The anesthesia code set remains stable with no proposed changes to any base unit values. There are updates to codes and values for some interventional pain procedures. ASA led the efforts to obtain new codes to describe genicular nerve injection and destruction procedures and worked with other societies to establish new codes for sacroiliac joint injection and radiofrequency ablation. To address some confusion of over proper use and reporting of many somatic nerve injection codes (CPT® codes 64400 – 64450), some of the codes in this family have been revised or deleted and all were subject to re-valuation. Many ASA members were randomly selected to participate in the surveys that are part of that process and we are grateful to those who responded. We are disappointed with the values that CMS is proposing for some of these services and will express our concerns to CMS during the rule’s 60-day comment period.
Evaluation and Management (E/M): In this rule, CMS steps back from its previously finalized plan to compress the payment levels for E/M services provided in the office or outpatient setting (CPT codes 99201-99205 and 99211-99215) and instead, proposes to accept the recommendations from the CPT Editorial Panel and the AMA/Specialty Society RVS Update Committee (RUC). These recommendations include deletion of code 99201 and significant revisions to the criteria to determine the level of service for this series of E/M services. CMS also proposes to increase values for office/outpatient E/M services at level three and above. Because these services have such high utilization throughout medicine, all specialties will be impacted by these changes. Those that do not report the higher-level codes could see some significant negative impact due to budget neutrality implications. The E/M changes are slated for CY 2021 so we may see more on this before they take effect.
Quality Payment Program:
Merit- based Incentive Payment System (MIPS): CMS continues provide the annual updates to the MIPS program. For the 2020 Performance/2022 Payment period, per statute, the potential negative adjustment rises to 9%. In order to avoid a negative adjustment, CMS is proposing that eligible clinicians (EC) and groups participating in MIPS will need to earn a score of 45 points – an increase from the 30 points required to avoid a negative adjustment in the 2019 Performance/2021 Payment period.
The weights assigned to each component of the program are proposed to change with Quality decreasing to 40% and Cost increasing to 20%. Promoting Interoperability and Improvement Activities are proposed to remain at 25% and 15% respectively.
CMS has proposed to include the Multimodal Pain Management measure in the Anesthesiology Measure Set. That measure was developed by a joint ASA-ASRA Measure Development Panel and has been reportable via our Qualified Clinical Data Registry (QCDR) for two years.
CMS also seeks to simplify MIPS reporting and better align activities within each component of the program via a MIPS Value Pathway (MVP). CMS envisions a program in which a MIPS EC or group with be in one MVP that is specific to their specialty or to conditions they treat. All within that MVP would report on the same set of measures. MVPs would become applicable in 2021.
Alternative Payment Models (APMs): CMS is offering proposals to streamline APM participation in MIPS which include pathways for those in a MIPS APM to use MIPS Quality measures if quality scoring is not available to them via the APM.
Other Policies to Note:
The Proposed Rule includes other items of specific interest to ASA members. These include options to treat opioid use disorders and solicitation of comments on the Stark law advisory opinion process. It also includes a proposal to allow a nurse anesthetist (ie CRNA) to examine a patient immediately before surgery to evaluate the risk of anesthesia and the risk of the procedure for services performed in an Ambulatory Surgery Center. This proposal follows inquires to CMS from ASCs and industry associations seeking to align the anesthetic risk and pre-surgery evaluation with pre-discharge standards. Patients will always be ASA's highest priority and we cannot and will not support any proposal that could compromise patient safety.
ASA will submit comments to CMS before the close of the 60-day comment period. CMS will issue a final rule with its decisions in November which will – unless otherwise specified – become effective January 1, 2020.
The proposed regulations are available here
The fact sheet is available here
The QPP factsheet is available here