What Medicare’s 2020 PFS changes mean for optometry
Medicare's 2020 Physician Fee Schedule (PFS) reflects AOA advocacy on key program changes slated to affect optometry, including revisions to Evaluation and Management (E/M) codes and Quality Payment Program reporting requirements.
Released by the Centers for Medicare & Medicaid Services (CMS) on Nov. 1, the final rule updates payment policies, rates and quality provisions for services furnished under the PFS come Jan. 1, 2020, and reportedly reflects administration efforts to improve accessibility, quality, affordability, empowerment and innovation. Specifically, the final rule updates E/M code changes and relative value of services that will take effect in 2021; updates quality reporting requirements for 2020, including those under the Merit-based Incentive Payment System (MIPS); clarifies Qualified Clinical Data Registry (QCDR) recommendations for 2021; and approves program alterations related to prescription or opioid drug initiatives in 2021.
In July, CMS proposed policy changes that would impact how doctors of optometry and other physicians furnish care and get reimbursed for CY2020. The AOA responded in public comments with recommendations to individual proposals, many of which now are reflected in the final rule.
Barbara L. Horn, O.D., AOA president, says the final rule demonstrates how effectively AOA advocates on behalf of the profession and ensures optometry isn't overlooked in decisions affecting Medicare.
"Each year, CMS updates these payment rules and policies with an aim toward improving the quality and efficiency of care," Dr. Horn says. "Our AOA is vital for keeping tabs on how these policies may directly or indirectly affect optometry, and our aim is to proactively advocate for improvements to the Medicare program that benefit our doctors and patients."
MIPS changes, new framework
In addition to clarifying quality measures and reporting requirements under MIPS, CMS' final rule introduced a new framework for clinicians to participate in the future.
Called MIPS Value Pathways (MVP), this new model would move away from the current state of MIPS-requiring clinicians to report across performance categories, including Quality, Cost, Promoting Interoperability and Improvement Activities (IAs)—to a program that allows clinicians to select among clinically related, specialty-specific measurement sets to report on commensurate with their scope of practice.
While the AOA cautioned CMS to carefully consider timing and rollout of MVP, CMS agreed to work with stakeholders in a meaningful way to ensure this initiative can further reduce reporting burden and ease the transition to Advanced Payment Models.
Additionally, CMS finalized criteria surrounding "topped out" measures and removal of measures under MIPS. The AOA argued that rather than eliminating "extremely" topped out measures, CMS should raise the data completeness threshold for those retained measures to allow physicians with limited reporting options the ability to continue program participation. So, too, the AOA recommended that measures should only be removed when a measure steward restricts access to the measure by QCDRs, and CMS agreed, determining a measure may be removed if determined it is not available for MIPS quality reporting by or on behalf of all MIPS eligible clinicians.
Lastly, the AOA raised concerns with CMS' proposal to increase group reporting thresholds to at least 50% of a group's clinicians to receive credit for an IA, adding that it's a significant policy change and increase over the previous requirement of only one clinician from a group. The CMS finalized a modified version, such that at least 50% of a group's clinicians must perform the same IA for any continuous 90 days in the performance period beginning with the 2020 performance year. This should allow clinicians flexibility to choose the most appropriate 90-day period while still increasing participation.
E/M office visits
Continuing CMS' goal to reduce physician burden and improve the accuracy of payments for E/M visits , the final rule confirms changes to documentation policies, as well as coding and payment changes to take effect Jan. 1, 2021. These E/M coding changes align with the Current Procedural Terminology (CPT) framework and Relative Value Scale Update Committee (RUC) recommendations for E/M office visits.
The CPT coding changes retain 5 levels of coding for established patients and reduce the number of levels to 4 for office/outpatient E/M visits for new patients, and revise code definitions. Additionally, the CPT code changes also revise the times and medical decision-making process for all of the codes and allow clinicians to choose the E/M visit level based on either medical decision-making or time.
The E/M revision process is several years in the making and the AOA has been engaged from the start, stressing that any E/M add-on codes should not be specialty-specific but open to all physician types. The final rule retains that approach and doctors of optometry can now report the add-on code for primary care and patients with serious conditions.
The AOA notes that while CMS estimates a small reduction for optometry, this could prove inaccurate if doctors' usage of E/M codes changes in the coming year and higher-level E/M codes are reported. Additionally, CMS did not consider that doctors of optometry would report the add-on code for primary care or patients with serious or complex conditions.
Pertaining to the valuation of codes, CMS finalized the AOA's recommendation to adopt RUC-recommended work and practice expense values for Corneal Hysteresis Determination (CPT code 92145) and Ophthalmoscopy (CPT codes 92201 and 92202).
Higher Medicare Part B deductibles
Increased spending on physician-administered drugs also predicated CMS' increase on enrollees' Medicare Part B premiums and deductibles in 2020. Both monthly premiums and deductibles will rise nearly 7%, meaning doctors of optometry will likewise need to adjust their deductible to $198 from $185.
Lastly, CMS estimates that doctors of optometry will have total allowed charges of $1.33 billion in 2020, as compared to a 2019 estimate of $1.30 billion.
Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2024, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.