2020 Medicare Fee Schedule Wins Praise, Brickbats

Stakeholders criticize updated conversion factor, praise increased payments for E/M visits.

This article was first published on Tuesday, July 30, 2019 in MedPage Today.

By Shannon Firth, Washington Correspondent, MedPage Today.

WASHINGTON -- The proposed rule for 2020 Medicare payment rates for U.S. physicians garnered mixed reactions from stakeholders.

Taking into account certain budget neutrality adjustments in relative value units (RVUs) as required by law, the 2020 Medicare Physician Fee Schedule released Monday establishes a conversion factor of $36.09, up $0.05 from 2019, for an overall increase of 0.14%.

The proposed rule aims to give clinicians' more time with their patients by scrapping unnecessary measures and shrinking their paperwork burden, explained Seema Verma, administrator for the Centers for Medicare & Medicaid Services (CMS), in a press release.

"Clinicians are drowning in paperwork and reporting requirements caused by cumbersome government rules and regulations. These administrative costs add to the total cost of delivering healthcare," she said, noting that practices often hire additional staff to keep up with requirements.

CMS would for the first time pay clinicians for care managment services for patients with a "high-risk chronic condition," such as diabetes or high blood pressure, according to the agency. It would also pay clinicians more for managing the care of a patient with multiple conditions.

Anders Gilberg, vice president for the Medical Group Management Association (MGMA), described the rule overall as "mostly status quo."

That the conversion factor has "remained flat" for several years and increased only a nickel from 2019 is a frustration for MGMA members who feel the fee schedule isn't keeping up with the cost of practice inflation, he stated.

While the changes to chronic care management, which recognize the work clinicians do outside of a traditional office visit, appear positive, Gilberg said the complexity around billing for these codes has often left MGMA members frustrated.

Having to jump through hoops -- for instance, paying a claims processing fee of $7 to retrieve a $2 coinsurance, and requiring physicians themselves to obtain patient consent for such bills -- it's often not worth the effort for members to bill the code, he said. MGMA supports legislation in Congress to waive the coinsurance for Medicare beneficiaries for these services.

Gilberg said he's not sure whether the proposal addresses these underlying concerns, but that's a question he'll be discussing with MGMA members before the group submits its comment letter.

The American Medical Group Association (AMGA) was critical of the rule, stating that proposed changes to the Merit-based Incentive Payment System (MIPS) "do not reflect congressional intent" or adequately reimburse its members.

Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), providers were supposed to be able to earn as much as a 9% bump on their Medicare payments in 2022, based on 2020 performance, but the proposed rule sets an overall payment adjustment of 1.4%, according to AMGA.

"By proposing an overly cautious approach, CMS is not rewarding those organizations that made the necessary investments in and championed value-based care as envisioned by congressional leaders," Jerry Penso, MD, MBA, AMGA president and CEO, said in a press statement.

CMS appears to have reversed course on a proposal to overhaul evaluation and management (E/M) codes that would have paid physicians the same amount for an office visit with a complex patient as a healthy one. The proposal was initially met with intense backlash from medical groups.

"Consistent with our goals of burden reduction, we are proposing to align our E/M coding with changes laid out by the CPT Editorial Panel for office/outpatient E/M visits," said an updated CMS fact sheet.

"The CPT coding changes retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients, and revise the code definitions. The CPT changes also revise the times and medical decision making process for all of the codes, and requires performance of history and exam only as medically appropriate. The CPT code changes also allow clinicians to choose the E/M visit level based on either medical decision making or time," according to the CMS.

Kavita Patel, MD, a primary care internist and vice president at Johns Hopkins Medicine in Baltimore, told MedPage Today she was relieved to see the changes in E/M coding.

Patel was "incredibly worried" that non-procedural specialties -- including primary care, rheumatology, medical oncology -- would be penalized under the previous approach to E/M codes, but it appears "[CMS] made some changes for the better."

While she said she's concerned that stakeholders could conflate these E/M changes with a path towards value on the fee schedule, to achieve that goal would require correcting mis-valued services. "But I think it's a step in the right direction," she said.

The American Medical Association (AMA) said it was pleased to see the changes CMS proposed around documenting and coding for E/M services. AMA President Patrice Harris, MD, noted in a press release that the AMA and other medical groups helped CMS develop the new proposal.

"The proposed changes to documenting and coding for office visits will streamline reporting requirements, reduce note bloat, improve workflow, and contribute to a better environment for health care professionals and their Medicare patients," Harris said, highlighting an AMA website that offers background on the new approach to E/M documentation.

Ted Okon, executive director for the Community Oncology Alliance, also applauded the E/M changes.

"Instead of simply collapsing or reducing reimbursement for evaluation and management ... services as proposed in past years, CMS has realized that the complexity of cancer care is valuable, as is the expertise and time of the community oncologists who treat patients with complex cancers," he said in a press statement.

The changes to E/M coding were "in many ways ... what we were looking for," he told MedPage Today during a phone interview at which a press representative was present. However, "in reality CMS is more or less walking back a number of its own proposals," he added.