How the Medicare Physician Fee Schedule Final Rule for 2020 may impact your specialty

On Nov. 1, the Centers for Medicare & Medicaid Services (CMS) published the Medicare Physician Fee Schedule Final Rule for calendar year (CY) 2020. The final rule updates payment rates and policy changes for services effective on or after Jan. 1, 2020. The final rule also includes updates for the Quality Payment Program (QPP). Collectively, these rules directly impact physician payment and practice.

Before being finalized, the proposed rule was published over the summer with a public comment period. During that time, the AOA reviewed the 800+ pages in proposed changes to the Physician Fee Schedule and QPP and submitted comments on the proposed rules.

One significant factor impacting the Physician Fee Schedule is that any changes to the fee schedule must be budget-neutral. This means that an upward adjustment in payment for an existing or new code requires an offset or downward adjustment in another area.

This summary includes policy changes and updates to payment rates under the CY 2020 rule. Find a more detailed summary from the AOA’s public policy team here. CMS will accept comments on these changes until Dec. 31, 2019. AOA staff will continue to review the final rule and provide a separate update on the Quality Payment Program.

Key payment policy provisions in the final rule

Conversion factor

The CY 2020 Physician Fee Schedule conversion factor is $36.09, an increase of five cents from the current conversion factor of $36.04. The anesthesia conversion factor will decrease from $22.27 to $22.20 for CY 2020.

CMS applied a 0.14% budget neutrality adjustment to both conversion factors and an additional -0.46% practice expense and malpractice adjustment to the anesthesia conversion factor. There was no statutorily required conversion factor update for CY 2020.

Final estimated specialty RVU impacts

Specialties that bill a high number of E/M visits will likely see payment increases next year, and those that do not generally bill E/M visits will likely experience payment decreases.

The table below shows the estimated combined RVU impacts of the final Evaluation and Management (E/M) payment and coding policies for some specialties. Other policy changes finalized for CY 2020 are not reflected in the table. The actual impact will vary depending on geographic location and the mix of services provided in a practice. The entire estimated specialty level impacts are listed in Table 120 of the final rule.

Evaluation & management visits

CMS finalized its proposal to overhaul the coding, payment and documentation guidelines for office/outpatient E/M visits (CPT codes 99202-99205 and 99211-99215) confirmed in the CY 2019 final rule for CY 2021. The AOA worked closely with the CPT Editorial Panel and the RUC to develop the new coding framework and payment rates.

Starting Jan. 1, 2021, the following changes will take effect:

• Eliminate uniform payment rates for E/M levels two – four. In CY 2019, CMS finalized a policy to blend payment rates. Starting in CY 2021, CMS will pay for each level of service separately, and adopt revised work and practice expense inputs.
• Retain five E/M levels for established patients (99211-99215) and reduce the E/M levels from five to four for new patients (99202 – 99205). E/M visit 99201 will be deleted since the level of medical decision making (MDM) for 99201 and 99202 are both straightforward and only differ by history and exam.
• Allow clinicians to choose E/M visits based on MDM or total time (including face-to-face and non-face-to-face time). The history and/or exam for E/M code selection will only be required when medically necessary.
• Adopt a new add-on CPT code (99XXX) for prolonged office/outpatient E/M visits and eliminate GPRO1 previously finalized for CY 2021. The new code will be used to report time spent on the date of service for a level five office/outpatient E/M visit (99205 or 99215) that exceeds 15 minutes or more. Starting in CY 2021, CPT codes 99358-99359 (Prolonged E/M without Direct Patient Contact) will not be reportable with office/outpatient E/M visits.
• Consolidate the previously finalized add-on CPT codes for complex or chronic primary care and specialty cases into a single code (GPC1X), billable with all office/outpatient E/M visits.

The American Osteopathic Information Association Physician Services Department will provide information and assistance to help members understand the new guidelines and code revisions in the coming weeks. More information on the E/M revisions and a copy of the E/M MDM grid are available on the American Medical Association website.

For CY 2020, physicians may continue to use either the “1995” or “1997” E/M Documentation Guidelines for coding and billing office/outpatient E/M visits to Medicare.

The final rule will be published in the Federal Register on Nov. 15.