News November 02, 2019

CMS releases 2020 Medicare Physician Fee Schedule and Quality Payment Program Final Rule

On November 1, 2019, the Centers for Medicare and Medicaid Services (CMS) released the 2020 Medicare Physician Fee Schedule (MPFS) and 2020 Quality Payment Program (QPP) Final Rule. The rule will affect how physician anesthesiologists will be paid via Medicare in 2020 and how their QPP performance will affect their future 2022 payments.

As part of its comments on the proposed rule, ASA advocated for appropriate payment levels for anesthesia and pain medicine services, appropriate changes to the Quality Payment Program.

	2019	Proposed 2020	Final 2020
RBRVS	$36.0391	$36.0896	$36.0896
Anesthesia	$22.2730	$22.2774	$22.2016

Source: CMS-1715-F and IFC, Table 117: Calculation of the Final CY 2020 PFS Conversion Factor. Table 118: Calculation of the Final CY 2020 Anesthesia Conversion Factor. November 1, 2019.

The difference in the proposed and final anesthesia conversion factors is due to a negative adjustment for practice expense and malpractice changes. These were slated to be a positive 0.27% in the proposed rule and was contingent on CMS finalizing all proposals as presented in the rule. In this Final Rule, the adjustment is a negative 0.46%. Practice expense and malpractice changes are assigned at the code level in RBRVS services, unlike the anesthesia payment methodology in which they are expressed via the conversion factor.

ASA is disappointed and displeased that CMS finalized the work values as proposed for the somatic nerve injection codes and continue to disagree with the agency’s rationalization for this decision. We do note that ASA was successful in convincing CMS to increase some specific practice expense components in the new codes that describe procedures on genicular nerves.

Specialty	Allowed Charges (mil)	Impact of Work RVU Changes	Impact of Practice Expense RVU Changes	Impact of Malpractice RVU Changes	Combined Impact
All Specialties	$93,487	0%	0%	0%	0%
Anesthesiology	$2,002	0%	0%	0%	0%
Interventional Pain Management	$890	0%	1%	0%	1%
Nurse Anes / Anes Asst	$1,297	0%	0%	0%	0%

Source: CMS-1715-F and IFC. Table 119: CY 2020 PFS Estimated Impact on Total Allowed Charges by Specialty. November 1, 2019.

ASA is pleased that as part of the FY 2020 Medicare Physician Fee Schedule Final Rule, CMS did not extend the scope of nurse anesthetist practice.

CMS originally proposed to allow nurse anesthetists expansive authority to “examine the patient immediately before surgery to evaluate the risk of anesthesia and the risk of the procedure to be performed [emphasis added]. However, CMS withdrew that proposal based on ASA comments and the comments of ASA members. CMS acknowledged that “nurse anesthetist training is limited to anesthesia care delivery, not risk assessment, diagnosis, or medical decision making outside the scope of an anesthetic.” CMS clarified that “immediately before surgery, a physician must examine the patient to evaluate the risk of the procedure to be performed, and a physician or anesthetist must examine the patient to evaluate the risk of anesthesia.”

This provision does not alter Medicare’s longstanding policy supporting physician-led team-based models of care.

CMS finalized several provisions for the MIPS program for 2020 performance period (2022 payment period):

Out of 100 MIPS points available, 45% will be allocated to Quality, 15% to Cost, 25% to Promoting Interoperability (formerly Advancing Care Information) and 15% to Improvement Activities.
The performance threshold for 2020 is 45 MIPS Total Points – up from 30 MIPS Total Points. Eligible Clinicians (ECs) or practices who fail to participate, when required, or to meet the 45-point threshold may incur up to a negative 9% payment adjustment in 2022.
The MIPS Quality reporting threshold will increase from 60% of eligible cases per measure to 70% of eligible cases.
CMS approved MIPS #477, Multimodal Pain Management as a MIPS measure in the Anesthesiology Measure Set starting in 2020.

ASA is pleased that CMS recognizes physician anesthesiologist leadership role in applying multimodal pain management and its assignment of this measure as “high priority.”
ASA physicians and staff will continue to review this 2,475 page rule and publish additional updates and materials in the coming weeks.

Final Rule: https://s3.amazonaws.com/public-inspection.federalregister.gov/2019-24086.pdf

Press Release: https://www.cms.gov/newsroom/press-releases/trump-administration-strengthens-medicare-reducing-provider-burden-and-valuing-time-spent-patients

Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/finalized-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar

ASA Comments on Proposed Rule (September 2019): https://www.asahq.org/advocacy-and-asapac/fda-and-washington-alerts/washington-alerts/2019/09/asa-urges-changes-to-cms-proposals-for-the-2020-medicare-physician-fee-schedule