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On July 29, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) proposed rule. The MPFS proposed rule sets Medicare payment rates for calendar year (CY) 2020 and addresses other related Medicare policies. The proposed changes will be finalized in early November 2019 and will apply to Medicare Part B services furnished on or after January 1, 2020.

The proposed rule is open for comment through September 27, 2019. AADE is conducting a full analysis of the proposed rule and will submit comments to CMS addressing areas relevant to diabetes care and education specialists.

AADE has highlighted key provisions that may be of interest to members. Additional information can be found on the CMS fact sheet.

Payment Conversion Factor

CMS estimates a conversion factor of $36.09, a slight increase from the 2019 conversion factor of $36.04. The conversion factor is used to calculate the payment rate for services paid under the MPFS.

Valuation for Diabetes Self-Management Training (DSMT) Codes (G0108 and G0109)

CMS did not propose any changes to the DSMT benefit or related codes- G0108 (Diabetes outpatient self-management training services, individual, 30 minutes) and G0109 (Diabetes outpatient self-management training services, group session (2 or more patients), per 30 minutes). See Table 1 for the estimated payment rates for 2020. The values will be finalized in November when CMS releases the MPFS final rule.

Table 1:

AADE continues to advocate for changes to the DSMT benefit both through our legislative efforts in advancing the Expanding Access to DSMT Act (H.R. 1840/S. 814) and through ongoing discussions with and comments to CMS. 

Physician Supervision Requirements for PAs

CMS proposes to revise the regulation that establishes supervision requirements for PAs. The proposed change would provide PAs with greater flexibility to practice more broadly in the current healthcare system and would more closely align supervision requirements with state laws and scope of practice. Under the proposed revision, the physician supervision requirement would be met when a PA provides services in accordance with theirs state laws and scope of practice rules. In the absence of state law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA’s approach to working with physicians in furnishing their services.

Review and Verification of Medical Record Documentation

CMS addressed feedback regarding the undue burden created when physicians and other practitioners, including those serving as clinical preceptors for states, must re-document notes entered into the medical record by other members of the medical team. CMS proposes to establish a general principle allowing the physician, PA, or APRN who provides and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. This principle would apply across the spectrum of all Medicare-covered services paid under the MPFS and address the concerns over provider burden.

Payment for Evaluation and Management (E/M) Services

CMS proposes to use the revised E/M code definitions developed by the AMA’s CPT Editorial Panel. These revisions would take effect beginning January 1, 2021. Under this proposal, CMS would 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 E/M code definitions. CMS also proposes to incorporate recommendations from the AMA Relative Value Scale Update Committee (RUC) to adopt revised work and practice expense inputs for E/M services.  

Transitional Care Management (TCM) and Chronic Care Management (CCM) Services/Remote Patient Monitoring (RPM)

TCM Services: CMS proposes to increase payment and ease billing restrictions surround TCM services. TCM services are care management services provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays. CMS seeks to improve utilization of TCM services relative to the number of Medicare beneficiaries with eligible discharges.

CCM Services: CMS also proposes a set of Medicare-developed HCPCS G codes for certain CCM services.  CCM is a service for providing care coordination and management services to beneficiaries with multiple chronic conditions over a calendar month service period. These Medicare-specific codes would allow clinicians to bill incrementally to reflect additional time and resources required in certain cases and better distinguish complexity of illness as measured by time. CMS also proposes adjusting certain billing requirements and elements of the care planning services.  These changes would also reduce burden associated with billing the complex CCM codes.

Chronic Care RPM: In the CY 2019 MPFS, CMS finalized reimbursement for the newly created CPT code 99457 to describe remote physiological monitoring treatment management services. In September 2018, the CPT Editorial Panel revised the CPT code structure for CPT code 99457 effective January 1, 2020. The new code structure maintains CPT code 99457 as a base code that describes the first 20 minutes of services and uses a new add-on code (994X0) to describe subsequent 20-minute intervals of service.

The new code descriptors for 2020 are:

CPT code 99457: Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; initial 20 minutes.

CPT code 994X0: Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes.

In addition to the coding changes, CMS also proposes to change the supervision requirements for billing of clinical staff time spent on RPM services reported with CPT codes 99457 and 994X0. CMS proposes that these services may be provided under general supervision rather than the currently required direct supervision. In addition, CMS states that RPM services (CPT codes 99457 and 994X0) should be included as designated care management services. Designated care management services can be billed under general supervision.

Updates to the Quality Payment Program

CMS proposes a series of changes to the Quality Payment Program with the goal of streamlining program requirements and reducing clinician burden.  This includes the introduction of the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs), a conceptual participation framework that would apply to future proposals beginning with the 2021 performance year. The MVP framework seeks to align and connect measures and activities across the Quality, Cost, Promoting Interoperability, and Improvement Activities performance categories of MIPS for different specialties or conditions. In the proposed rule, CMS provided an example of an MVP for diabetes and how an endocrinologist might participate. CMS is accepting comments on how best to engage stakeholders on the development of MVPs and feedback on proposed MVP examples. Click here for more information on 2020 updates to the Quality Payment Program.

AADE will continue to review the provisions in the MPFS proposed rule for CY 2020. Once the MPFS final rule is released in November, AADE will highlight any changes for the upcoming year that directly affect our members.