First look at new Medicare rules for 2020

The U.S. Centers for Medicare and Medicaid Services (CMS) released its annual proposal for changes to the Medicare payment system for the coming year. CMS also released new information about the existing mandate for the use of clinical decision support (CDS) beginning in 2020.

Sandy Coffta from Healthcare Administrative Partners.

The Medicare Physician Fee Schedule (MPFS) proposed rule contains not only proposed adjustments to Medicare reimbursement but also proposed changes to the Quality Payment Program (QPP) for 2020 and beyond.

Unlike in some recent years, the proposed MPFS does not contain many significant changes, especially for radiology. In fact, the big news is that the mandate requiring the use of a qualified CDS mechanism (CDSM) to consult appropriate use criteria (AUC) is not mentioned at all in the proposed rule!

There will be some revaluation for ultrasound procedure codes and future adjustments to fine-needle aspiration reimbursement, but the majority of the proposed rule deals with refinement of the QPP.

Appropriate use criteria/clinical decision support

The AUC/CDS Medicare payment rule was established in the 2014 Protecting Access to Medicare Act (PAMA) and was finally codified in the MPFS final rule for 2018, as we previously reported. CMS has just released Change Request (CR) 11268 confirming that the Educational and Operations Testing Period will begin on January 1, 2020, as expected, with full implementation to begin on January 1, 2021, when payment will be denied for certain advanced imaging services that do not meet the ordering criteria.

The change request now defines the coding to be used by the radiologist for reporting the CDSM consult by the ordering physician. A modifier will be attached to the relevant procedure code to describe either the level of adherence to AUC or an exception to the program, as shown in the following table.

Modifiers MA, MB, MC, and MD denote exceptions to the use of a CDSM, and payment will not be denied when a hardship exists. Although CDSM consultation is not required at either a critical access hospital (CAH) or a federally qualified health center (FQHC), no modifier exists to claim an exemption for services provided in such facilities.

When a CDSM has been consulted and modifier ME, MF, or MG is indicated, then a G-code will be reported on a separate line to identify the CDSM.

CMS noted that multiple G-codes may appear on a single claim, when appropriate.

Medicare fee schedule payment and valuation changes

The fee schedule conversion factor is expected to increase by 0.14% to $36.04 per relative value unit (RVU) for 2020, although this figure is usually modified somewhat by the time the final rule is released in November. CMS' estimates of overall impact are shown below.

However, within the final fee schedule there will likely be significant swings in the reimbursement level for individual procedures, as the proposed rule includes more than 100 new or revised codes that relate to radiology. Of these, 41 will decrease in value.

Quality Payment Program

The QPP is only 4 years old, and it is still being fine-tuned and adjusted. This is due in part to a strategy by CMS to help physicians ease into the program, changing thresholds and levels each year until it becomes a stable program. The table below shows the progression of some of the thresholds and other values as they are now proposed to change from 2019.

Quality performance category

As noted in the table above, the weight of the Quality category is proposed to decrease over time. However, as many radiologists do not receive a score in the Cost category, the Cost weight is redistributed to Quality; therefore, Quality will continue to represent at least 60% of the score for many radiologists, and it could be even more for a hospital-based practice where the Promoting Interoperability value is also redistributed.

The requirement for data completeness is proposed to increase from 60% to 70% of either Part B patients (for those reporting claims submission) or all patients for the other data submission methods.

In addition to the current criteria for measure removal, the proposed rule would remove quality measures that do not meet case minimum and reporting volumes required for benchmarking for two consecutive years, or if CMS determines that a measure is not available for reporting by or on behalf of all clinicians eligible for the Merit-Based Incentive Payment System (MIPS).

Improvement Activities performance category

The proposed rule will add two new activities, modify seven existing activities, and remove 15 activities. Until now there has been no formal policy to determine which activities would be removed from the inventory, but the proposed rule establishes factors that will enter into this decision by CMS. The factors proposed are as follows:

• The activity is duplicative of another activity.
• An alternative activity exists with a stronger relationship to quality care or improvements in clinical practice.
• The activity does not align with current clinical guidelines or practice.
• The activity does not align with at least one meaningful measures area.
• The activity does not align with the other QPP performance categories.
• There have been no attestations of the activity for three consecutive years.
• The activity is obsolete.

The threshold for reporting an improvement activity in a group or virtual group would be raised from participation by one clinician in the group to at least 50% of the group's MIPS-eligible clinicians, with at least 50% of the group's clinicians performing the same activity for the same continuous 90-day period. Other proposed changes involve rural practices and patient-centered medical homes (PCMHs).

Promoting Interoperability performance category

A group practice that is determined under the rules to be "hospital-based" has until now been reweighted out of the Promoting Interoperability category when 100% of the MIPS-eligible clinicians meet the definition. This threshold is proposed to be changed to 75% of the National Provider Identifiers (NPIs) in the group. Groups that are considered "nonpatient facing" under the existing rules will be automatically reweighted. The impact of reweighting is that the category's 25% value in the final score is assigned to the Quality category. Refer to the table of proposed weights above.

The only changes to the Promoting Interoperability objectives and measures would be to remove the "Verify Opioid Treatment Agreement" measure and to keep the "Query of Prescription Drug Monitoring Program (PDMP)" measure optional.

Cost performance category

There are currently three measures within the Cost category:

• Total Per Capita Cost (TPCC)
• Medicare Spending Per Beneficiary (MSPB)
• Episode-Based Measures

Of these, generally only the MSPB might apply to radiology practices. In the proposed rule, the name of this measure has been revised to be MSPB Clinician (MSPB-C) and the specifications would also be revised. The TPCC specifications will also be revised, and 10 new Episode-Based Measures are proposed to be added to the eight existing ones.

Final score calculations

CMS has some latitude for reweighting scores in certain circumstances such as for extreme and uncontrollable events and other hardships. Additional policies are proposed that would allow reweighting performance categories in "rare events" due to compromised data outside the control of the MIPS-eligible clinician. If CMS determines that the reweighting is appropriate, it would redistribute the scores to both the Promoting Interoperability and Quality categories, but only rarely to the Cost category.

Conclusion

The proposed rule is subject to comments from the public and interested organizations that will potentially modify its proposals. Following this process, the final rule is due to be released in November, and we will provide a thorough analysis at that time.

Sandy Coffta is vice president of client services at Healthcare Administrative Partners.

The comments and observations expressed are those of the author and do not necessarily reflect the opinions of AuntMinnie.com.