2020 Physician Fee Schedule Summary - Texas Orthopaedic Association

The Centers for Medicare and Medicaid Services (CMS) released its final payment rule for the calendar year (CY) 2020 Physician Fee Schedule (PFS) payment policy on Friday, November 1.

CMS finalized most of the orthopaedic-related proposals that were published in this summer’s proposed rule. Therefore, this summary will simply touch on a few of the subjects.

Click here to view TOA’s summary of the proposed rule.

Click here to read AAOS’ comments in response to the proposed rule.

Click here to read the final rule.

New, Revised & Potentially Misvalued Codes
AAOS’s stakeholder letter addressed many of the new, revised, and potentially misvalued codes that were proposed by CMS this summer.

TOA’s coding course on Friday, February 7 in San Antonio will take a deeper look at the final outcome for these codes.

E/M Codes
TOA’s summary of the proposed rule outlined the changes for E/M codes, and those were finalized in this final rule. Beginning in 2021, CMS will align its E/M coding with changes adopted by the AMA’s CPT Editorial panel:

Established patients will have five levels.
New patients will have four levels.

The final rule will also rely on the AMA’s RUC committee’s recommended values for office/outpatient E/M codes for 2021 and a new add-on CPT code for prolonged service time.

Quality Payment Program (QPP)
AAOS provided extensive comments to CMS’s proposed rule related to the QPP. Stay tuned to AAOS for a full analysis of the full rule.

Some of the final rule’s highlights include:

CMS finalized the proposal to increase the minimum number of points that physicians must receive in order to avoid a negative payment adjustment under MIPS (from 30 points in 2019 to 45 points in 2020).

CMS finalized the proposal to transition MIPS to a new conceptual framework called MIPS Value Pathways in CY 2021. Instead of focusing on quality, cost, improvement activities, and promoting interoperability, the new program will focus on:

Close alignment with alternative payment models (APMs).
Outcome-based measures.
Specific to a physician’s specialty or a given condition.

Physical Therapy
Several payment issues related to physical therapy were included in the final rule:

Congress passed a law that required the addition of a code modifier to services that were delivered by a PTA, which CMS interpreted in this summer’s proposed rule to mean that physical therapy services delivered in part by a PTA would receive a decreased payment beginning in 2022. CMS backed off that proposal in the final rule.
Overall, physical therapy will witness a payment cut in the final rule due to CMS’s budget-neutrality requirement.
Dry needling codes were added, but CMS won’t pay for them until a national coverage determination makes the recommendation. CMS stated that they should be defined as “sometimes therapy” procedures.

Opportunities for Bundled Payments Under the PFS
CMS asked for comments related to additional opportunities for bundled payments under the PFS. Its commentary can be found in the final rule beginning on page 854. Per CMS:

Identifying and developing appropriate payment policies that aim to achieve better care and improved health for Medicare beneficiaries is a priority for CMS. Consistent with that goal, we are interested in exploring new options for establishing PFS payment rates or adjustments for services that are furnished together.

As noted in the CY 2020 PFS proposed rule, we are actively exploring the extent to which these basic principles of bundled payment, such as establishing per-beneficiary payments for multiple services or condition-specific episodes of care, can be applied within the statutory framework of the PFS.

CMS indicated that it received a number of recommendations and will consider these in the future.

Global Surgical Packages
As always, global surgical packages are examined in Medicare’s PFS annual rule. CMS attempted to eliminate 10- and 90-day global surgery packages in a past rule. However, Congress re-instated them in the MACRA legislation with the stipulation that CMS must continue to study these global packages.

CMS’s commentary on the issue begins on page 898 of the final rule. If you don’t want to read through the comments and responses, this is the main takeaway from CMS:

After considering the comments, we are not making changes in the values of global surgery procedures to reflect changes we are making in this final rule beginning in CY 2021 to coding and values for stand-alone E/M services. We anticipate continuing to assess and develop an approach to revaluing global surgery procedures, including the associated post-operative visits. We appreciate all the comments on the three RAND reports and we will study them as we go forward. For the specialty societies that expressed concern that our current method does not accurately account for the data, we welcome submissions on other methods of gathering the data or ways to tabulate the results.

The following is a look at the comments and responses in the final rule.

Comment: Most commenters objected to not using the proposed new E/M coding and valuations to revise the values for global surgery packages. The commenters stated that failure to use the new E/M coding and values for global services will disrupt the relativity in the PFS, create specialty differences and could violate the MACRA section 523(a) statutory requirements.

Most commenters objected to our not proposing to adopt the AMA RUC recommendations to apply revised values for E/M office visits in global surgery procedures. They stated that not adopting the RUC recommendations interferes with relativity because we proposed to apply the RUC-recommended E/M values to stand-alone E/M services, but not to the E/M services that are included in global surgical packages. Commenters noted that in the past, CMS has aligned changes in valuation of stand-alone office visits with valuation of the office visits in the surgical global period so that each time the value for separately billed office visits was changed, corresponding changes were made to the value of visits for all global surgery packages. In addition, some commenters stated that, by failing to adopt all of the RUC-recommended work and time values for the revised office visit E/M codes, including the recommended adjustments to the 10- and 90-day global codes, CMS is implementing these values in an arbitrary and piecemeal fashion. Some commenters stated that applying the RUC-recommended E/M values to stand-alone E/M services, but not to the E/M services that are included in the global surgical package, would result in disruption to the relativity between codes across the Medicare PFS. A number of commenters also stated that failing to adjust the global codes to reflect adjustments to separately billable E/M services is tantamount to paying some physicians less for providing the same E/M services, in violation of the law.

Response: Relativity is an important concept we consider heavily when establishing values for services under the PFS. To maintain relativity in the past, we had adjusted values for global surgery procedures when we updated values for E/M visits because we did not have information to suggest that it might not be appropriate to do so. However, there are now important, unresolved questions regarding how post-operative visits included in global surgery codes should be valued relative to stand-alone E/M visit analogues. Specifically, it is unclear whether it would be appropriate to use a building-block approach to increase the valuation for global surgical packages in a way that could disrupt potentially more accurate estimates of total work for procedures with global periods from magnitude estimation. Furthermore, given the information described above on E/M services furnished as part of global surgery services, we have questions about the appropriate number of E/M services reflected in the values for global surgery procedures. If the number of E/M services for global codes is not appropriate, adopting the AMA RUC-recommended values for E/M services in global surgery codes would exacerbate rather than ameliorate any potential relativity issues. Therefore, we are not adopting the RUC recommendation to apply revised values for E/M services to the global surgery codes at this time.

Section 1848(c)(8)(C) of the Act, as added by section 523a of the MACRA, requires CMS to use the information collected as appropriate, along with other available data, to improve the accuracy of valuation of surgical services under the PFS. We believe it is important to avoid contributing further to the potential misvaluation of global surgical procedures. Reflexively adding revised E/M work RVUs to values for global codes as recommended by the RUC and other commenters could potentially result in inappropriate shifts in relativity under the PFS, and the associated BN adjustment could result in potentially inappropriate adjustments to payment rates for services without global periods, such as separately-billed E/M visits. Given that the information we have gathered to date as required by section 1848(c)(8)(B)(i) of the Act, as well as the conclusions of past OIG studies, suggests that the values for E/M services typically furnished in global surgery periods are overstated in the current valuations for global surgery codes, we do not believe it would be appropriate to amplify the effects of any such overvaluation by increasing the values of included E/M services while we continue to look into the information and develop appropriate solutions.

Comment: Commenters raised concerns about the generalizability of the claims data we collected on post-operative visits since it was only collected from practices with 10 or more practitioners in 9 states. One commenter stated that the AMA 2018 Physician Practice Benchmark Survey indicated that 54 percent of physicians are in practices with fewer than 10 physicians. They added that, for surgical specialties, 64 percent of physicians are in practices with fewer than 10 physicians. Commenters expressed a related concern that the definition of “practice” used in the reporting of post-operative visits caused confusion and decreased reporting. Further, commenters expressed concern that some physicians may not have been aware of the reporting requirement, and therefore, some post-operative visits were not reported. One commenter noted that using CPT 99024 to report post-operative visits contradicts specialty society coding education, and some practices encountered difficulties reporting the zero-charge CPT 99024 as attempts to report the code in many practices and EHR systems are blocked by the software.

Response: We believe that the newly-collected post-operative visit data significantly improves our understanding of which bundled post-operative visits are actually furnished during global periods, beyond estimates provided by the AMA RUC and specialty society surveys. CMS chose to limit reporting to a random sample of 9 states and to exclude practices with less than 10 practitioners because of concerns from the physician community about reporting burden, which might be particularly high for smaller practices. Some commenters have now suggested that the scope of our required reporting may be inadequate. We can consider for the future whether requiring reporting for smaller practices and throughout the country would give us better data. We also note that, although we have authority to do so, we chose not to penalize practitioners who did not report, but we could also reevaluate this decision if the current reporting rates are insufficient.

Comment: Commenters disagreed with the conclusion in the RAND report that only 39 percent of expected post-operative visits following procedures with 90-day global periods and only 4 percent of expected post-operative visits following procedure with 10-day global periods were actually performed. Commenters objected to counting all non-occurring visits as “no” visits as some visits were not reported. Relatedly, commenters raised many concerns with the methodology used in the RAND analyses. These include:

- Revaluations from the RUC have made the data outdated.
- Potential flaws in the way procedures were matched to reported 99024 codes.
- Disagreement with the definition of “robust reporters” used in the sensitivity analyses.
- Possible bias from the use of half-visits from the time file.
- Reporting of procedures with 10-day global periods are dominated by HCPCS codes

17000, 17004 and 17110, which are not representative of all procedures.

- Inclusion of separately-billed E/M services to provide post-operative care could account for the gap between observed and expected visits.

Response: The RAND results focus on the share of expected post-operative visits that were reported to CMS. It is true that the absence of a reported visit does not necessarily mean that a post-operative visit did not occur. However, apart from required reporting, we have no way to know whether a visit occurred. For some specialties, including hand surgery, orthopedic surgery, vascular surgery, ophthalmology, neurosurgery, urology, plastic and reconstructive surgery, dermatology and general surgery, 85 percent or more of practitioners who were expected to report post-operative visits relating to global surgical services reported at least some visits. We can only assume the visits that are furnished are being reported.

The RAND report includes results from many sensitivity analyses that aim to address several methodological concerns raised by some commenters, and particularly concerns related to potentially incomplete reporting. While different sensitivity approaches slightly increase or decrease the number of reported post-operative visits we would expect to see, none results in findings that differ substantially from the report’s main conclusions that a small share of expected post-operative visits for procedures with 10-day global periods, and less than half of expected post-operative visits for procedure with 90-day global periods, appear to actually occur. RAND will be issuing a report in response to each of these methodological concerns later this year. This report will also be posted on the CMS website.

Comment: MedPAC supported CMS’ decision to not adopt the RUC’s recommendation that CMS adjust the work RVUs for postoperative E/M visits that are part of surgical codes with 10-day and 90-day global periods. MedPAC cited evidence that 10-day and 90-day global surgical codes are overvalued. Several other commenters agreed that we should not adjust values for the global surgery codes to reflect revised values for E/M visits. For example, one commenter stated, “[W]e believe it would be imprudent to adjust the E/M component [of global surgery codes] because of any changes to the values of stand-alone office/outpatient visit codes 99201-99215 and we support CMS’ decision in this regard.” Another commenter expressed support for CMS’ “efforts to collect this information and ensure an appropriate number and type of E/M codes bundled with the 10-day and 90-day globals.”

Response: We agree that it would be imprudent at this point to adjust the values for surgical codes with 10- and 90-day global periods to reflect the values for stand-alone E/M visits.