Proposed 2020 Fee Schedule Sees Bump in Payment, Streamlining of Documentation

Psychiatrists will see on average a slight uptick in reimbursement under the Medicare program in 2020, according to the proposed 2020 fee schedule issued last month by the Centers for Medicare and Medicaid Services (CMS). Additional increases are expected for the 2021 fee schedule.

CMS is also proposing changes that will simplify documentation for evaluation and management (E/M) services and establish “bundled payments” for patients being treated for an opioid use disorder (OUD). (Bundled payments provide a single payment for all services provided over a defined episode of care.)

Those are the highlights of a proposed 2020 fee schedule that APA staff said is mostly good news for psychiatrists. In addition to the fee schedule, which governs coding and reimbursement, the CMS rule also includes proposed updates and changes to the Quality Payment Program. The latter includes proposed rules for the two quality programs in which physicians can participate: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

Comments on the proposed rule are due September 27. The final rule will be issued on November 1.

These are some of the proposed changes for 2020:

• There will be a slight increase to the “conversion factor” by which relative value units (RVUs) are translated into dollars, from $36.04 per RVU to $36.09 per RVU. This, in combination with other proposed changes, will increase the total allowed charges for psychiatry (and the total overall amount paid to psychiatrists) by 1%. How that will play out for individual psychiatrists will depend on their patient mix and practice type. (RVUs are composed of the values for physician work, practice expense, and malpractice costs associated with every billable code. The RVUs are established by the Relative Value Update Committee, or RUC, which includes representatives from APA.)

• CMS proposes requiring performance and documentation of a patient history and exam only as medically appropriate; further, the agency proposes allowing clinicians to bill the E/M visit based on either the level/amount of medical decision-making involved or on the amount of time spent providing care. (The latter proposal removes the requirement that—in order to bill by time—at least 50% of the time must be spent in counseling and coordination of care.)

• CMS is removing the requirement that physicians re-document information entered by other members of a clinical team and proposes allowing physicians to document they have reviewed the information rather than requiring them to restate it.

• CMS is proposing to add to the suite of Care Management Services a new code that describes Principle Care Management Services. This would pay for care management activities that physicians, including psychiatrists, provide to patients with a single, high-risk, or chronic condition. (Care Management Services is a broad term for activities that physicians or their staff do on behalf of patients when the patient is not in a face-to-face clinical encounter. Until recently, Medicare paid for only a limited set of activities that occurred when the patient was not in the office, and the agency is now proposing to add another code to the options available.)

• CMS is also proposing several changes related to care of individuals with OUD. These include a proposal to establish bundled weekly payments for services, including medication, provided by opioid treatment programs, a treatment setting whose services have not been covered by Medicare.

• CMS has also proposed a set of bundled monthly payments for services provided to patients with OUD who are receiving care in the office or outpatient setting. APA staff will continue to review these to ensure that the appropriate range of services is included and reimbursed at a sufficient rate.

CMS is revising its proposal, set to take effect in 2021, to collapse the existing levels of services and payment for outpatient E/M services. Instead, CMS proposes (in accordance with changes adopted by the Current Procedural Terminology Editorial Panel) to reduce the number of levels of care to four for office/outpatient E/M visits for new patients while retaining the current five-level structure for established patients.

Updates to CMS’s Quality Payment Program impact the two arms of this value-based payment program— MIPS and APMs. Specific updates regarding the four MIPS reporting categories—Quality, Cost, Promoting Interoperability (or certified electronic health records), and Improvement Activities—are still being analyzed by APA staff.

However, one possibility for the 2021 performance year of which physicians should be aware is CMS’s proposed MIPS Value Pathways (MVPs).

The MVPs are a conceptual framework for streamlining the different MIPS categories as listed above. The goal is to move away from the current, siloed activities and measures toward a streamlined set of measures relevant to a clinician’s scope of practice.

So, for instance, psychiatrists assigned to a particular MVP would collect data on the same measures and activities as other psychiatrists assigned to that MVP. In a statement on the CMS website summarizing the Quality Payment Program proposals, CMS said, “We believe this would streamline MIPS reporting, reduce complexity and burden, and improve measurement.” ■