CMS Finalizes Changes to QPP, Medicare Fee Schedule
By Joey Berlin

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Changes to Medicare’s Quality Payment Program (QPP) finalized Friday include both wins and losses for medicine, according to Texas Medical Association staff's initial analysis of the QPP final rule for 2020. 

The Centers for Medicare and Medicaid Services (CMS) released the mountainous 2,475-page 2020 Medicare physician fee schedule on Friday, which includes changes to QPP and its main quality track, the Merit-Based Incentive Payment System (MIPS). 

Among the rule’s notable elements on MIPS, which is entering its fourth year of implementation: 

  • The low-volume threshold, which exempts physicians based on their Medicare patient, services, or billing volume, will remain unchanged. A decrease in the threshold criteria would have required more physicians to participate in MIPS. 
  • CMS will reweight categories if circumstances outside physicians' control make their data for certain performance categories inaccurate or unusable, rather than giving physicians a score of zero and an automatic payment penalty. This could include compromised data due to an electronic health record vendor’s technological problems. Re-weighting will begin for the 2018 performance year, which affects physician payments in 2020. 
  • The scoring threshold to earn a bonus payment increases from 30 points this year to 45 points in 2020. A score of less than 45 points leaves a physician subject to a payment cut of up to 9%. 
  • The threshold to earn an additional bonus for exceptional performance will be 85 points next year, up from 75 this year. 
  • MIPS Value Pathways (MVPs), a new framework that CMS says consists of “integrated measures and activities that are meaningful to all clinicians from specialists to primary care clinicians and to patients,” will debut during 2021. 

Angelica Ybarra, TMA’s director of clinical advocacy, says the rule includes some positives for physicians, such as the low-volume threshold staying the same and the reweighting of categories to account for extenuating circumstances, which TMA had long advocated for. 

However, Ms. Ybarra says, the QPP is still becoming more rigorous in terms of its data and overall performance requirements while not making adequate adjustments for physicians who have inherent disadvantages in the program, such as small and solo-group practices. The 45-point threshold may be unreachable for most small practices, resulting in payment cuts for many Texas physicians, she adds. 

On the Medicare fee schedule side, CMS once again touted its goal to free up clinicians to focus on patients instead of paperwork. The 2020 rule includes changes to outpatient evaluation and management (E&M) office visits for new patients that will take effect in 2021, reducing the number of payment levels for those visits to four instead of five. For established-patient visits, the fee schedule will retain five levels of coding, CMS says. 

 “As a result of these updates, starting Jan. 1, 2021, clinicians will be able to make better use of their time and restore the doctor-patient relationship by spending less time on documenting visits and more time on treating their patients,” CMS said. 

During last year’s rulemaking period for the 2019 fee schedule, medicine warned CMS against a proposal to reduce the number of E&M outpatient office visit levels for both new and established patients, and to collapse the payment schedule for the various visit levels. Its advocacy successfully persuaded CMS to delay changes for two years. At the time, CMS left the door open for further stakeholder engagement on the topic. 

CMS also finalized its proposal to change payment for various care management services:

  • Transitional care management services will receive a payment increase.
  • CMS is creating a specific code for chronic care management services that can be used for time spent beyond the time currently allowed.
  • The agency also created a new code for principal care management, which is for any physician who treats patients with only a single serious condition and high-risk chronic condition. 

TMA staff will be digging into the rule this week for a full read on how it will affect physicians participating in Medicare. In the meantime, you can read more on the rule on CMS fact sheets for the fee schedule and QPP.

Last Updated On

November 04, 2019

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Joey Berlin

Associate Editor

(512) 370-1393
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Joey Berlin is associate editor of Texas Medicine. His previous work includes stints as a reporter and editor for various newspapers and publishing companies, and he’s covered everything from hard news to sports to workers’ compensation. Joey grew up in the Kansas City area and attended the University of Kansas. He lives in Austin.

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