The Release of the 2020 Physician Fee Schedule Final Rule: Important changes health plans and other payers need to know

Blog Posts  |  10 December 2019

The 2020 Physician Fee Schedule final rule was published on November 1, 2019 by the Centers for Medicare and Medicaid Services (CMS). The final rule updates provisions for services furnished under the Medicare Physician Fee Schedule (PFS) and builds off previously developed policies established in former years. The Medicare payment structure and services covered have been redefined in 2020 to better reflect some of the current issues plaguing both doctors and patients. Below are the finalized proposals of key interest to health plans and payers that will go into effect as of January 1, 2020.

Evaluation and management billing

To combat the growing problem of provider burden and the resulting burnout, updates were made to evaluation and management billing requirements.

  • The number of levels associated with new patient office and outpatient evaluation and management visits has been reduced to four.
  • CMS revised code definitions as part of a coordinated effort to pay for each level of service rather than use the previously blended rates.

These revised definitions will allow providers to choose the evaluation and management visit level based on time or medical decision making.

Medicare will now cover opioid use disorder treatment services furnished by opioid treatment programs (OTPs)

Under the rulings finalized in the SUPPORT Act in 2018, beginning January 1, 2020 Medicare must begin supporting numerous opioid use disorder treatment services. Examples of these services include substance use counseling, group therapy, and FDA approved opioid agonist and antagonist medications used for treatment. Bundled payment rates, based on the medication given to patients during a one-week treatment period, will also be available for OTPs. In order to be eligible for the bundled payment rates provided by CMS, OTPs must first enroll in Medicare.

To increase the access to and quality of patient care for those suffering from opioid use disorder, the following Health Care Common Procedural Code System (HCPCS) codes have been added to the telehealth services list: G2086, G2087, and G2088. These three codes will be used for Medicare to identify bundled episodes of care for the treatment of opioid use disorder. This will enable greater coordination and greater access to care for the beneficiary.

Increasing care management services

To enhance the value of beneficiary care, CMS has finalized a proposal to increase payment for transitional care management services. These are the services that are provided to Medicare beneficiaries post discharge from an inpatient stay, and under certain circumstances outpatient stays.

To better classify the care delivered to beneficiaries, CMS has also created a Medicare specific code that will be used to identify encounters where additional time is spent with the patient. These encounters would last beyond the basic 20 minutes that are currently allowed in the coding schema for care management services classified as chronic.

  • The first 20 minutes clinical staff spend performing chronic care management services may be billed under CPT code 99490.
  • The remainder of the time spent with the patient performing chronic care management services will be billed in 20- minute increments under the CPT code G2058.

Approaching January 1, 2020

The changes laid out in the Physician fee schedule final rule surrounding billing and services included under the Medicare payment structure are numerous and represent an intention to modernize healthcare and acknowledge the current issues within the medical system. The Veradigm regulatory team is dedicated to tracking, monitoring, and taking the necessary steps to ensure all of our partners are equipped with the information and tools needed to be successful in the coming year of billing and payment changes.

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