FEE SCHEDULE SUMMARY: AAFP ADVICE VISIBLE IN CMS FINAL RULE

Evaluation and Management Services

The Academy had long advised CMS that undervaluation of evaluation and management (E/M) services slowed crucial investments in primary care. As supported by the AAFP, the final rule aligns E/M coding with changes laid out by the current procedural terminology (CPT) Editorial Panel for office and outpatient E/M visits, starting in 2021. This means that

• 5 levels of coding will be retained for established patients

• The number of levels will be reduced to 4 for office and outpatient E/M visits for new patients

• The times and medical decision-making process for all office-based E/M codes will be revised, and performance of history and exam will be required only as medically appropriate

• Clinicians will be able to choose the E/M visit level based on either medical decision making or time

CMS finalized the adoption of Academy-supported, American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee- recommended values for the office and outpatient E/M visit codes for 2021, as well as a new add-on CPT code for prolonged service time.

Quality Payment Program

As outlined in a CMS executive summary of the 2020 Quality Payment Program, the merit-based incentive payment system will operate with the following performance thresholds and category weights for the 2020 performance period (which equates to the 2022 payment year):

• Performance threshold: 45 points

• Additional performance threshold for exceptional performance: 85 points

• Quality performance category weight: 45%

• Cost performance category weight: 15%

• Promoting interoperability performance category weight: 25%

• Improvement activities performance category weight: 15%

For the 2021 performance period, however, CMS has raised the performance threshold to 60 points, with the additional performance threshold for exceptional performance remaining at 85 points.

Coverage for Opioid Treatment Programs

In a move the Academy backed, the 2020 MPFS establishes Medicare coverage for medication-assisted treatment for opioid use disorder (OUD).

CMS finalized the creation of new coding and payment for a monthly bundle of services for treatment of OUD that includes overall management, care coordination, individual and group psychotherapy, and substance use counseling, as well as an add-on code for additional counseling.

Outpatient Prospective Payment System

Also on November 1, 2019, CMS also issued “Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs” as a final rule with comment period.

The Academy had encouraged CMS in a September 19, 2019 letter to consider site-of-service payment parity from a broader perspective and to create incentives for services to be performed in the most cost-effective location, such as a physician’s office.

The final rule includes a policy that continues to eliminate differential payments between certain outpatient sites of service, completing a 2-year phase-in of the move to reduce unnecessary utilization in outpatient services by addressing payments for clinic visits furnished in the off-campus hospital outpatient setting. This could save Medicare beneficiaries $160 million and the Medicare program $650 million in 2020.

However, CMS did not finalize an Academy-backed proposal to require hospitals to disclose prices for all supplies, tests, and procedures. A separate final rule on the issue is expected in the future, the agency said.