2020 Proposed CMS Rule for the Medicare Physician Fee Schedule: CMS-1715-P

On August 14, 2019, CMS published the proposed rule for the 2020 Medicare physician fee schedule. Overall, CMS estimates that emergency medicine will undergo a 1% increase in payments in 2019.

 

The basic payment formula remains: (RVU work x GPCI work) + (RVU P.E.  x GPCI P.E.) + (RVU M x GPCI M) = RVU TOTAL x Conversion Factor = Fee for each CPT® Code

 

Conversion Factor Updates

The April 2015 MACRA (Medicare Access and CHIP Reauthorization ACT) legislation provided a permanent fix to the SGR-related conversion factor reduction. CMS estimates a 2020 conversion factor of 36.0686. The 2019 conversion factor is 36.0391. This represents a 0.14% increase in the 2020 conversion factor versus 2019. 

 

MACRA called for 0.50% annual increases in the conversion factor for 2016 through 2019. These 0.50% increases have not occurred for a variety of reasons. Because of budget neutrality provisions ingrained within the Medicare physician fee schedule, the conversion factor is used to balance out any items that cause increased Medicare spending over projected amounts.

 

Relative Value Units for 2020

CMS has proposed modest RVU changes for emergency service codes in 2020. For 2020, the Work RVUs are slightly increased for certain codes based on a revaluation exercise conducted by the AMA RUC. Practice Expense RVUs are nearly identical to 2019. Surprisingly, Malpractice RVUs were increased for most codes. Table One illustrates the proposed 2020 RVUs for emergency services codes, and compares RVUs to 2019 values. In comparison to 2019, total RVU values have increased by 2.0% in 2020.

 

Table One

Code

2019

RVUW

2020

RVUW

2019 RVUpe

2020 RVUpe

2019 RVUm

2020

RVUm

2019 RVUt

2020 RVUt

99281

0.45

0.48

0.11

0.11

0.04

0.05

0.60

0.64

99282

0.88

0.93

0.21

0.21

0.08

0.09

1.17

1.23

99283

1.34

1.42

0.29

0.29

0.12

0.17

1.75

1.88

99284

2.56

2.60

0.53

0.51

0.23

0.26

3.32

3.37

99285

3.80

3.80

0.74

0.72

0.35

0.42

4.89

4.94

99291

4.50

4.50

1.39

1.38

0.39

0.42

6.28

6.30

Table Two illustrates the expected “national value” fees for emergency services evaluation and management codes.

Table Two

CPT Code

2019 Fee ($)

2020 Fee ($)

% Change

99281

21.62

23.10

1.48

99282

42.17

44.39

2.22

99283

63.07

67.85

4.78

99284

119.65

121.62

1.97

99285

176.23

178.28

2.05

CMS Revisions to Documentation Guidelines and Payments for Office Visits

In 2017, CMS stated that potential revisions to the Documentation Guidelines (DGs) were being considered. As medical practices have evolved significantly since publication of the 1995 and 1997 DGs, providers have continually appealed to CMS for much-needed revisions. Stakeholders have expressed concerns with the following elements that plague both sets of guidelines:

  • Complexity

  • Ambiguity

  • Failure to distinguish meaningful differences among code levels

  • Failure to account for significant changes in technology given implementation of electronic health records

  • Potential for up-coding due to prevalence of automated code level application

  • Audit vulnerability

  • Administrative burden.

 

In the 2020 Proposed Rule, CMS accepted CPT changes to existing Medical Decision Making and time documentation guidelines for office visits. Coincidentally, CMS is abandoning the documentation guidelines proposed for 2019 that required documentation need only be at the level of 99202 for codes 99202 through 99204 or at the level of 99212 for codes 99212 through 99214. Simultaneously, CMS is abandoning the single-blended payment rate for 99202 through 99204 and 99212 through 99214.

 

 

Tables Three and Four illustrate the abandoned blended rate for new and established office visits.

 

Table Three

CPT Code

Prior Payment

Revised Payment Abandoned

99201

$45

$45

99202

$76

$135

99203

$110

$135

99204

$167

$135

99205

$211

$211

Table Four

CPT Code

Prior Payment

Revised Payment Abandoned

99211

$22

$22

99212

$45

$93

99213

$74

$93

99214

$109

$93

99215

$148

$148

Redistribution

In the Rule, CMS is proposing groundbreaking payment policy changes that will result in significant redistribution of Medicare physician payments to primary care providers in office based settings. CMS is proposing significant increases in Work RVUs for the office visit CPT codes based upon a revaluation exercise performed by the AMA RUC. Also, CMS is proposing two additional codes that are intended to be used by primary care providers.  Via the budget neutrality provisions of the Medicare Physician Fee Schedule, increases in office visit payments will come at the expense of providers who derive payments from sites of service outside the office. Emergency services fall into this latter category. Payments for evaluation and management services currently compose 40% of Medicare physician payments, with office visits accounting for half of that amount. By increasing office visit payments across the board, budget neutrality requires a reduction in Medicare payments for all other CPT codes. The mechanism that CMS will use in order to maintain budget neutrality is a reduction in the conversion factor.

 

CMS is proposing that increased office visit payments begin in 2021. This timeframe allows interested parties to comment on this major new CMS payment policy. The 2021 Medicare Physician Fee Schedule Final Rule will be published in November 2020. BSA Healthcare expects that specialties other than primary care will vigorously oppose this new payment policy, especially the reduction in payments to non-primary care providers. 

 

CMS is also proposing elimination of CPT code 99201 – new patient office visit. Tables Five and Six illustrate the new Work RVUs that the RUC proposed and ones that CMS is proposing.

 

Table Five

CPT Code

Current RVUw

RUC RVUw

CMS RVUw

99201

N/A

N/A

N/A

99202

0.93

0.93

0.93

99203

1.42

1.60

1.60

99204

2.43

2.60

2.60

99205

3.17

3.50

3.50

 

Table Six

CPT Code

Current RVUw

RUC RVUw

CMS RVUw

99211

0.18

0.18

0.18

99212

0.48

0.70

0.56

99213

0.97

1.30

1.30

99214

1.50

1.92

1.81

99215

2.11

2.80

2.80

CMS also proposed the addition of two codes for use by primary care providers. The first code, prolonged services for every 15 minutes, would have Work RVU of 0.61. The second is a HCPCS code for additional work, and would have a Work RVU of 0.33.

 

Effects on Emergency Services E&M Codes

Because of budget neutrality lowering of the conversion factor, if the proposed new code valuations and additional codes are finalized by CMS, the following reductions in emergency services payments can be expected in 2021:

  • If CMS implements RUC-recommended RVUw for office visits – negative 7%

  • If CMS implements CMS-refined RVUw for office visits – negative 3%

  • Other variations – negative 4% to 6%.

There are a number of variables that may influence the final impact for emergency medicine. First, if CMS chooses to institute their own recommended office visit Work RVU changes versus those suggested by the RUC, providers would realize a 4% impact. Second, expected robust negative comments by non-office visit specialties may sway CMS over the next 12 months. Finally, emergency service E&M codes 99281 through 99283 have always had a Work RVU linkage to office visit codes 99201 through 99203 (and by extension, the higher levels 99284 and 99285). If the RUC and CMS uphold this link, the Work RVU values for 99281 through 99285 may increase.

BSA Healthcare’s opinion is Emergency Medicine needs to begin coalition advocacy efforts now in order to reverse a negative impact in 2021 on emergency service E&M fees as well as fee reductions for other codes utilized by coalition partners.

 

Close Menu