The final CY 2020 Outpatient Prospective Payment System (“OPPS”) and Medicare Physician Fee Schedule (“MPFS”) rules have been released by the Centers for Medicare & Medicaid Services (“CMS”).
Most notably, CMS did not address the proposed price transparency requirements. Instead, CMS delayed their response, to the issuance of another forthcoming final rule, the date of which has not been specified. CMS stated that it has received over 1,400 comments regarding the price transparency proposals and that its review process is ongoing.
If finalized, the proposed price transparency rule would require hospitals to publicly post “gross charges” as reflected on the hospital chargemaster, “payer-specific negotiated charges”, and charges for at least 300 common shoppable items and services listed on hospital websites.
The final rules contain other notable changes, however, such as modifying office/outpatient Evaluation & Management (“E/M”) billing and coding, adding ASC and outpatient eligible surgical services, enhancing Part B opioid use disorder treatment benefits, and continuing site neutral provider-based and 340B payment changes.
CMS discussed the recent site neutral and 340B federal court rulings at length, both of which are adverse to the CMS authority. However, CMS again presented its arguments in support of its payment reduction policies, and signaled the possibility of additional appeals. This shows a likelihood of continuing court challenges where site neutral and 340B payment changes are concerned.
CMS OPPS/MPFS Final Rules:
Key OPPS Changes
- Delay in Price Transparency Requirements
Over the last several years, the series of legislation and rulemaking has required hospitals to make public its standard charges for items and services provided. However, CMS delayed additional price transparency requirements to a forthcoming final rule, the date of which was not provided.
- Continuing Site Neutrality Despite Recent Court Order
Despite the recent federal court ruling reversing the CY 2019 payment reductions, the CMS CY 2020 OPPS Final Rule completes the two-year phase-in of site neutral payments for hospital off-campus clinic visits. This action will result in payments of 40 percent of the OPPS rate for clinic visits coded with HCPCS G0463 at all off-campus provider-based departments in CY 2020, including “grandfathered” rates under the BBA of 2015.
CMS acknowledged that the most recent district court order closed the case and vacated the CY 2019 payment reductions at 70% of the OPPS rate. This would seemingly require CMS to adjust CY 2019 claims that received reduced OPPS reimbursement for HCPCS G0463 clinic visit services in “grandfathered” off-campus provider-based departments. However, CMS did not explain how it will do this. Instead, CMS stated it is “working to ensure affected 2019 claims for clinic visits are paid consistent with the court’s order” while it evaluates whether to appeal the court’s decision.
- Changes to the Inpatient Only List
CMS changed the Inpatient Only (“IPO”) list by removing total hip arthroplasty, six spinal surgical procedures, and certain anesthesia services from the list. Removal make these procedures eligible to be paid by Medicare in the hospital outpatient setting and the hospital inpatient setting alike.
- ASC Covered Procedures List
CMS added Total Knee Arthroplasty (“TKA”), Knee Mosaicplasty, six additional coronary intervention procedures, and twelve procedures with new CPT codes to the ASC covered procedures list.
- Level of Supervision of Outpatient Therapeutic Services Changes
CMS reduced the minimum level of supervision required for hospital outpatient therapeutic services in hospitals and CAHs from direct supervision to general supervision. In short, this means the outpatient therapeutic service would have to be furnished under the physician’s overall direction and control rather than requiring the physician’s physical presence.
- Prior Authorization for Certain Hospital Outpatient Department (“HOPD”) Services
CMS finalized prior authorization requirements for Blepharoplasty, Botulinum Toxin Injections, Panniculectomy, Rhinoplasty, and Vein Ablation to limit Medicare coverage for these services to medically necessary scenarios only.
- Payment Methodology for 340B Purchased Drugs
For the time being, CMS will continue to pay ASP minus 22.5% for 340B drugs. However, CMS yet again acknowledged the on-going litigation and its current appeal of the recent covered entity-favorable decision. In the event that its appeal is denied, CMS summarizes potential remedies yet has not selected which approach it will take. Advis will continue to monitor this process and provide updates when available.
- OPPS and ASC Payment Increases
CMS increased the OPPS and ASC payment rates by 2.6 percent in CY 2020.
Key MPFS Changes
- Office/Outpatient Evaluation and Management (E/M) Services
CMS finalized E/M coding changes to align with the American Medical Association (“AMA”) for office/outpatient visits. The changes retain 5 levels of coding for established patients, reduce the number of levels to 4 for new patients, revise the times and medical decision-making process for all of the codes, and require performance of history and exam only as medically appropriate. Clinicians can continue to choose the E/M visit level based on either medical decision-making or time. CMS is also increasing payment for office/outpatient E/M visits, in line with the AMA Specialty Society Relative Value Scale Update Committee (“RUC”) recommended values.
- Revisions to Physician Supervision of PAs
In the absence of any contradicting state rules, CMS finalized a revision to supervision requirements to clarify that physician supervision is a process in which a PA has a working relationship with one or more physicians to supervise the delivery of their health care services. Such physician supervision is evidenced by documenting the PA’s scope of practice and indicating the working relationship(s) the PA has with the supervising physician(s) when furnishing professional services.
- Allowing Review and Verification as Opposed to Re-documentation
CMS will now allow physicians, physician assistants, and advanced practice registered nurses (“APRN”s – nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists) to review and verify (sign and date), rather than re-documenting, notes made in the medical record by other practitioners.
- Services Furnished by PTAs and OTAs
CMS finalized the policy to implement modifiers to identify therapy services that are furnished in whole or in part by physical therapy and occupational therapy assistants. CMS set a de minimis 10 percent standard for when these modifiers apply to specific services.
- Increase in Payment for Care Management Services
CMS finalized an increase in payment for care management service provided to beneficiaries after discharge from an inpatient stay or, in certain instances, outpatient stays. CMS also established a new Medicare-specific code for additional time spent beyond the initial 20 minutes allowed in the current coding for chronic care management (“CCM”) services. CCM services are provided over a calendar month to beneficiaries with multiple chronic conditions
- Part B Benefits for Opioid Use Disorder Treatment
CMS finalized plans to implement legislation that established a new Medicare Part B benefit for medication-assisted treatment of opioid use disorder, furnished by opioid treatment programs. CMS also finalized the creation of new coding and payment for a monthly bundle of services for the treatment of opioid use disorder that includes overall management, care coordination, individual and group psychotherapy, and substance use counseling, as well as an add-on code for additional counseling. The individual psychotherapy, group psychotherapy, and substance use counseling included in these codes could be furnished as Medicare telehealth services using communication technology where clinically appropriate. CMS also finalized new telehealth HCPCS codes G2086, G2087, G2088, which describe bundled episodes of care for treatment of opioid use disorders.
- Slight Increase in Conversion Factor
CMS increased the conversion factor slightly by $0.05 to $36.09.
For any questions regarding these changes, please contact Advis at (708) 478-7030.