by Kate Thomas, AADE Director of Advocacy
On November 1, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) final rule, which sets the Medicare payment rates for calendar year (CY) 2020 and addresses other related Medicare policies. The changes outlined in the final rule apply to Medicare Part B services furnished on or after January 1, 2020.
Before CMS released the final rule, AADE offered comments in response to the MPFS proposed rule for CY 2020 which was released in late July. The proposed rule allows interested stakeholders to weigh-in on the policies CMS is considering for inclusion in the final payment rule. AADE specifically addressed challenges that Medicare beneficiaries face when accessing the Diabetes Self-Management Training (DSMT) benefit and recommended improvements to the Medicare Diabetes Prevention Program (MDPP), including allowing virtual programs to participate in the MDPP, removing the once-per-lifetime limit, and adjusting reimbursement to cover reasonable costs. CMS did not address these issues in the final rule, though AADE continues to have ongoing dialogue with the agency on these important topics.
Below, AADE has highlighted key provisions from the final rule that may be of interest to AADE members. Additional information can be found on the CMS fact sheet and in this CMS presentation.
Payment Conversion Factor
CMS finalized the CY 2020 MPFS conversion factor is $36.09, a slight increase from the 2019 conversion factor of $36.04. The conversion factor is used to calculate the payment rate for services paid under the MPFS.
Valuation for Diabetes Self-Management Training (DSMT) Codes (G0108 and G0109)
CMS did not propose any changes to the DSMT benefit or related codes- G0108 (Diabetes outpatient self-management training services, individual, 30 minutes) and G0109 (Diabetes outpatient self-management training services, group session (2 or more patients), per 30 minutes). See Table 1 for the estimated payment rates for 2020.
AADE continues to advocate for changes to the DSMT benefit both through our legislative efforts in advancing the Expanding Access to DSMT Act (H.R. 1840/S. 814) and through ongoing discussions with and comments to CMS. As mentioned previously, in our proposed rule comments, AADE urged CMS to address the barriers that Medicare beneficiaries with diabetes face when trying to access DSMT services.
Chronic Care Remote Patient Monitoring (RPM)
In the CY 2019 MPFS, CMS finalized reimbursement for the newly created CPT code 99457 to describe remote physiological monitoring treatment management services. In September 2018, the CPT Editorial Panel revised the CPT code structure for CPT code 99457 effective January 1, 2020. The new code structure maintains CPT code 99457 as a base code that describes the first 20 minutes of services and uses a new add-on code (99458) to describe subsequent 20-minute intervals of service.
The new code descriptors for 2020 are:
CPT code 99457: Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; initial 20 minutes.
CPT code 99458: Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes.
In addition to the coding changes, CMS finalized changes to the supervision requirements for billing of clinical staff time spent on RPM services reported with CPT codes 99457 and 99458. CMS has included these codes as designated care management services, which may be provided under general supervision rather than the currently required direct supervision.
Review and Verification of Medical Record Documentation
CMS sought to address the undue burden created when physicians and other practitioners, including those serving as clinical preceptors for states, have to re-document notes entered into the medical record by other members of the medical team. In the final rule, CMS finalized broad modifications in their documentation policy to allow physicians, PAs, and advanced practice registered nurses (APRNs – nurse practitioners, clinical nurse specialists, certified nurse-midwives and certified registered nurse anesthetists) to review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, medical, physician assistant, and APRN students, nurses, or other members of the medical team.
Payment for Evaluation and Management (E/M) Services
CMS finalized their decision to align their E/M coding with the changes adopted by AMA’s CPT Editorial Panel. These revisions would take effect beginning January 1, 2021. Under this proposal, CMS would retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients, and revise the E/M code definitions. Visit the AMA’s CPT E/M website for more information.
Updates to the Quality Payment Program
CMS is in the process of implementing changes to Quality Payment Program with the goal of streamlining program requirements and reducing clinician burden. This includes the introduction of the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs), a conceptual participation framework that would apply to future proposals beginning with the 2021 performance year. The MVP framework seeks to align and connect measures and activities across the Quality, Cost, Promoting Interoperability, and Improvement Activities performance categories of MIPS for different specialties or conditions. In the MPFS proposed rule, CMS provided an example of an MVP for diabetes to illustrate the objectives of creating MVPs for a specific disease. CMS is continuing to explore the development of this MVP framework as a subset of measures and activities established by rulemaking, and announced that they will work with stakeholders to ensure a meaningful and cohesive experience for clinicians. AADE will stay engaged with CMS as they develop the MVPs and will look for specific opportunities for diabetes care and education specialists. For more information visit the MVPs website or watch this video: MIPS Value Pathways: The Future of MIPS.
AADE Perspectives on Diabetes Care
The American Association of Diabetes Educators Perspectives on Diabetes Care covers diabetes, prediabetes and other cardiometabolic conditions. Not all views expressed reflect the official position of the American Association of Diabetes Educators.
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