What You Should Expect in 2020: Changes to the Medicare Physician Fee Schedule
This coming 2020, there are going to be several changes to the Medicare Physician Fee Schedule that you should be aware of. Here are some of the major changes that you must know:
Physician Supervision Requirements for Physician Assistants (PAs)
“PAs must furnish their services in accordance with state law and state scope of practice rules for PAs in the state in which the services are furnished, with medical direction and appropriate supervision as required by state law in which the services are performed. 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.”
Now, PAs will be given greater flexibility so that they can practice more broadly in the current healthcare system. Of course, this should still be in accordance with state law and state scope of practice. In the absence of state rules, CMS is working on a clarification on the definition of physician supervision—that it would mean that the PA has a working relationship with one or more physicians to supervise the delivery of their healthcare services. This should be evidenced by documenting the PA’s scope of practice and indicating the working relationship between the supervising physician and the PA as they furnish their professional services.
Review and Verification of Medical Record Documentation
The CMS has proposed to establish a general principle that allows medical providers who furnish and bill for their professional services to review and verify (signature and date) information included in the medical record by physicians, residents, nurses, students or other members of the medical team, instead of re-documenting it. This will be applied across the spectrum of all Medicare-covered services paid under the Physician Fee Schedule. Included in the list of medical providers are physicians, physician assistants, advanced practice registered nurses, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, and certified nurse-midwives.
Transitional Care Management (TCM) Services
The CMS has proposed to revise the billing requirements for TCMs by permitting TCM codes to be billed alongside any of the 14 codes that were previously considered overlapping or duplicative. Review the table below.
It should be noted that there is a slight increase in work RVUs for TCM procedure CPT codes 99495, 99496.
Chronic Care Management (CCM) Services
There are two critical points when it comes to the changes in CCM Services this 2020:
- A new add-on HCPCS code for Chronic Care Management Services is proposed. It is described as each additional 20 minutes of clinical staff time directed by qualified healthcare professionals per calendar month.
- Separate coding and payment for Principal Care Management (PCM) services. These are care management services for one serious chronic condition. Such conditions typically last between 3 months to a year, or until the death of the patient. These could also have led to a recent hospitalization of the patient, or have put the patent at significant risk of death, acute exacerbation/ decompensation, or functional decline. At the moment, there aren’t any restrictions on the specialties that could bill for PCM.
“HCPCS code G2064 would be reported when, during the calendar month, at least 30 minutes of physician or other qualified health care provider time is spent on comprehensive care management for a single high-risk disease or complex chronic condition. HCPCS code G2065 would be reported when, during the calendar month, at least 30 minutes of clinical staff time is spent on comprehensive management for a single high-risk disease or complex chronic condition.”
Payment for Outpatient PT and OT Services Furnished by Therapy Assistants
Outpatient therapy services claims furnished in part or in whole by a therapy assistant should include the modifier effective for dates of service starting on January 1, 2020:
- CQ Modifier: Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant
- CO Modifier: Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant
The CQ and CO modifiers will trigger the application of the reduced payment rate (85%) for outpatient therapy services furnished in part or in whole by a PTA or OTA, beginning at services furnished in CY 2022.
A service is considered to be furnished in whole or in part by a PTA or OTA when more than 10 percent of the service (de minimis standard) is furnished by the PTA or OTA.
The modifiers apply to the following:
- Therapeutic portions of outpatient therapy services furnished by PTAs/OTAs, instead of administrative or other non-therapeutic services that can be performed by others without the education and training of OTAs and PTAs
- Services fully-furnished by PTAs or OTAs without physical or occupational therapists
- Evaluative services that are furnished in part by PTAs/OTAs. It should be noted that PTAs/OTAs are not recognized to completely furnish PT and OT evaluation or re-evaluations.
There are also some situations when the therapy assistant modifiers do not apply.
They do not apply when:
- PTAs/OTAs provide services that can be done by a technician or aide who does not have the training and education of a PTA/OTA
- Therapists exclusively furnish services without the involvement of PTAs/OTAs
CMS proposed to add a requirement that the treatment notes explain the application or non-application of the CQ/CO modifier for each service furnished that day. Here is an example of the note:
When PTAs/OTAs assist PTs/OTs to furnish services, the treatment note could state one of the following, as applicable:
(a) “Code 97110: CQ/CO modifier applied ‒ PTA/OTA wholly furnished”; or,
(b) “Code 97150: CQ/CO modifier applied ‒ PTA/OTA minutes = 15%”; or “Code 97530: CQ/CP modifier not applied ‒ PTA/OTA minutes less than 10% standard.”
For those therapy services furnished exclusively by therapists without the use of PTAs/OTA, the PT/OT could note one of the following: “CQ/CO modifier NA”, or “CQ/CO modifier NA ‒ PT/OT fully furnished all services.”
Therapy cap in 2020.
- For CY 2020: KX threshold amount is $2,080 for PT and SLP services combined and $2,080 for OT services.
- For CY 2020: the medical record threshold is $3,000 for PT and SLP services combined and $3,000 for OT services. Some, but not all claims exceeding the MR threshold amount, are subject to review, under the established targeted review process.
Coding and Payment for Evaluation and Management, Observation and Provision of Self-Administered Esketamine (HCPCS codes G2082 and G2083)
Patients with major depression disorder have not responded to treatment despite trying at least 2 antidepressant treatments given at adequate doses are considered to have treatment-resistant depression (TRD). To facilitate prompt beneficiary access to the new, potentially life-saving treatment for TRD using esketamine, CMS is creating two new HCPCS G codes, G2082, and G2083, effective January 1, 2020, on an interim final basis.
The HCPCS G-codes are described as follows:
- HCPCS code G2082: Office or other outpatient visits for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration; includes 2 hours post-administration observation.
- HCPCS code G2083: Office or other outpatient visits for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg esketamine nasal self-administration; includes 2 hours post-administration observation.
There is a 60-day public comment period following publication (on 11/01/19) of this interim final rule. This is to make sure that the public has a say on final amendments to CMS regulations.
Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs)
Starting January 2020, Medicare will pay enrolled OTPs bundled payments based on weekly episodes of care for services including:
- FDA-approved treatment medications for the treatment of OUD
- The dispensing and administration of such medications (if applicable)
- Substance use counseling
- Individual and group therapy
- Toxicology testing
Medicare will also make payment adjustments to the bundled payment amount for intake activities and periodic assessments. These are required by SAMHSA, as well as for additional counseling and therapy, and take-home supplies of medications.
Medicare patients will not have a copayment for OTP services in 2020. The Part B deductible will apply for OUD treatment services. To cover the OTP benefit, Medicare Advantage (MA) plans must use only OTP providers that meet the same requirements as those providing services under Medicare Part B, who are both certified by SAMHSA and enrolled in Medicare.
*Rates for the non-drug component will be adjusted by geographic locality and will be updated on an annual basis.
OTPs fully-certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and accredited by a SAMHSA-approved accrediting body can start enrolling in the Medicare program so they can bill for services starting January 1, 2020.
For CY 2020, CMS is adding the following codes to the list of telehealth services:
- HCPCS codes G2086, G2087, G2088: A bundled episode of care for treatment of opioid use disorders
- HCPCS code G2086: Office-based treatment for opioid use disorder, including the development of the treatment plan, care coordination, individual therapy, and group therapy and counseling; at least 70 minutes in the first calendar month
- HCPCS code G2087: Office-based treatment for opioid use disorder, including care coordination, individual therapy, and group therapy and counseling; at least 60 minutes in a subsequent calendar month
- HCPCS code G2088: Office-based treatment for opioid use disorder, including care coordination, individual therapy, and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (List separately in addition to code for primary procedure)
CY 2020 Estimated Impact on Total Allowed Charges by
Table above shows the payment impact on the Physician Fee Schedule services of the policies contained in the final rule. To the extent that there are year-to-year changes in the volume and mix of services provided by practitioners, the actual impact on total Medicare revenues will be different from those shown in the Table (CY 2020 PFS Estimated Impact on Total Allowed Charges by Specialty).
There are a lot of changes in store
for healthcare providers this coming 2020. Always read up on recent news in order
to make sure that your practice is ready for the changes and in compliance with
the new requirements!