Advocacy win

Proposed Medicare Physician Fee Schedule addresses DOs’ concerns

CMS has revised its payment plan for levels 2 through 4 Office/Outpatient Evaluation and Management (E/M) visits.

In a proposed rule released Monday, CMS revised its payment plan for levels 2 through 4 Office/Outpatient Evaluation and Management (E/M) visits for new and established patients.

Instead of collapsing the payment rates for level 2 through 4 E/M visits for new and established patients, CMS intends to adopt revised CPT guidelines for E/M visits and RVS Update Committee (RUC)-recommended values for CPT codes 99202-99215.

The change responds to strenuous objections from AOA and other physician groups to the previous plan that would have blended payment rates for E/M.

The AOA successfully advocated for the proposed payment changes through participation in revision of the E/M guidelines and a RUC survey that more than 50 specialty societies conducted to revalue physician work, practice expense inputs and time.

“The AOA appreciates the significance of CMS’ proposed policy changes that not only will further reduce administrative burden for physicians, but will establish payment rates that better reflect the work and resources currently used to provide E/M services for primary care and specialty physicians,” says AOA President Ronald Burns, DO, FACOFP.

Under the new framework, CPT code 99201 would be deleted, payment rates for CPT codes 99202 – 99215 would remain separate, and documentation would be based on new guidelines for medical decision making (MDM) or time. Use of history and/or physical exam to determine E/M code selection would be eliminated unless medically necessary and clinically appropriate.

CMS also proposes to delete the new add-on code (GPRO1) finalized last year for Prolonged Office/Outpatient E/M visits and establish a new code with a work RVU of 0.61 and 15 minutes of physician time.  To simplify new add-on codes previously finalized for primary (GPC1X) and specialty (GCG0X) care, CMS plans to consolidate both services into a single code.

Transitional care management and care coordination services

In 2018, the AOA advocated for an increase in transitional care management (TCM) services. For CY 2020, CMS proposes to adopt the RUC-recommended work RVU of 2.36 for CPT code 99495 and the RUC-recommended work RVU of 3.10 for CPT code 99496.

To further support care coordination for patients with multiple chronic conditions, CMS is proposing to create a set of Chronic Care Management (CCM) services to allow physicians to bill for the additional time and resources required for certain complex cases.

Physician supervision for physician assistant (PA) services

To better align supervision requirements for PA services with other non-physician practitioners, CMS is proposing to allow PAs to practice more broadly according to state laws governing scope of practice.

Other provisions in the proposed rule include updates to the Quality Payment Program and mandates for Medicare coverage of opioid treatment programs and the creation of a bundled episode of care for management of and counseling for opioid use disorder.

Next steps

The AOA will provide a detailed analysis of the proposed rule and submit comments to CMS. The proposed rule will be published in the Federal Register on Aug. 14, 2019.

Read the full AOA analysis of the proposed rule here.

Additional information on changes in the proposed rule will be available later this month.

Related reading:

4 recent scope of practice wins for DOs in Indiana, Hawaii and New Hampshire

American Board of Neurological Surgery apologizes to DOs it harassed


  1. Regarding the New Medicare Physician Fee Schedule……
    Will Modifier-25 codes still be allowed in the new fee schedule?
    (These codes are typically used to cover OMT procedures on the same day as E/M services.)

    1. In the Medicare Physician Fee Schedule (MPFS) proposed rule for calendar year 2020, CMS is not proposing any changes to the multiple procedure payment reduction (MPPR) policy that was finalized last year.

      In the 2019 MPFS final rule, CMS withdrew the MPPR proposal that would have impacted OMT services appended with Modifier -25. Should CMS reintroduce the MPPR policy in future rulemaking, it would only apply to Medicare and not private insurers.

      Until such time, OMT services billed with Modifier -25 under the Medicare program are status quo.

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