The Centers for Medicare and Medicaid Services (CMS) has released the annual changes to the Medicare Physician Fee Schedule (MPFS) in its Final Rule that contains not only adjustments to Medicare reimbursement but also revisions to the Quality Payment Program (QPP) for 2020 and beyond. The MPFS Final Rule does not contain very many significant changes for the coming year, especially for radiology, but one of its provisions will have a far-reaching effect on radiology beginning in 2021.
Medicare Fee Schedule Payment and Valuation Changes
The basic fee schedule conversion factor will increase by 0.14% to $36.09 per RVU for 2020, before adjustment for geographical differences. CMS estimates an overall impact as follows:
|No increase or decrease
|Radiation Oncology and Therapy Centers
|No increase or decrease
|No increase or decrease
The only way to really know the effect of the MPFS fee schedule changes on your own practice is to perform a volume variable analysis. The Final Rule includes over 100 new or revised codes that relate to radiology. Further analysis of the most significant changes will be provided in our subsequent review of the specific coding changes.
Radiologists in some practices might benefit from a rule change that will allow Physician Assistants (PA) greater flexibility. CMS has revised the PA supervision requirement such that the “physician supervision is evidenced by documenting the PA’s scope of practice and indicating the working relationship(s) the PA has with the supervising physician(s) when furnishing professional services”, according the CMS Fact Sheet. CMS notes that state law and scope of practice rules will primarily govern the work of PA’s.
Quality Payment Program (QPP)
The Final Rule maintains the MIPS Performance Category weights at the same level as they were in 2019, but the Performance Threshold and the Exceptional Performance Threshold have been increased for 2020 along with the possible range of penalty or incentive payments. These values are shown in the following table:
|Max/Min Payment Adjustment
|Performance Category Weights:
Quality Performance Category
Since many radiologists do not receive a score in the Cost category, the Cost weight will be redistributed to Quality; therefore Quality will continue to represent at least 60% of the score for many radiologists and it could be even more for a hospital-based practice where the Promoting Interoperability value is also redistributed.
The requirement for data completeness has been increased from 60% to 70% of either Part B patients (for those reporting claims submission) or of all patients for the other data submission methods.
In addition to the existing criteria for measure removal, CMS will remove quality measures that do not meet case minimum and reporting volumes required for benchmarking for 2 consecutive years, or if CMS determines that a measure is not available for reporting by or on behalf of all MIPS-eligible clinicians.
Two measures relevant to radiology have been removed:
- “Optimizing Patient Exposure to Ionizing Radiation: Reporting to a Radiation Dose Index Registry” (measure Q361), and
- “Optimizing Patient Exposure to Ionizing Radiation: Computed Tomography (CT) Images Available for Patient Follow-up and Comparison Purposes” (measure Q362).
CMS decided to retain two measures that had been proposed for removal:
- “Inappropriate Use of Probably Benign” (measure Q146) and
- “Reminder System for Screening Mammograms” (measure Q225).
The final Quality measure specifications are expected to be released by CMS near the end of 2019.
Improvement Activities Performance Category
The final rule adds 2 new activities, modifies 7 existing activities, and removes 15 activities. The threshold for reporting an Improvement Activity in a group or virtual group will be raised from participation by one clinician in the group, to at least 50% of the group’s clinicians performing the same activity for a continuous 90-day period, although it does not have to be the same 90-day period for all clinicians.
Promoting Interoperability Performance Category
The threshold for a group practice to be considered hospital-based will be lowered in 2020. Previously, 100% of the MIPS-eligible clinicians had to meet the definition. This threshold will now become 75% of the NPIs in the group.
Groups that are considered to be “non-patient facing” under the rules will be automatically re-weighted. The impact of re-weighting is that the category’s 25% value (see the table, above) in the final score is assigned to the Quality category.
Cost Performance Category
There are currently three measures within the Cost Category:
- Total Per Capita Cost (TPCC)
- Medicare Spending Per Beneficiary (MSPB)
- Episode Based Measures
Of these, generally only the MSPB might apply to radiology practices. The name of this measure has been revised to be MSPB Clinician (MSPB-C) and the specifications have also been revised. The TPCC specifications have also been revised, and 10 new episode-based measures have been added to the 8 existing.
Looking Ahead to 2021 and Beyond
Much of the content of the MPFS Final Rule each year sets the stage for provisions that will take effect in future years. For example, the MPFS Final Rule for 2018 finalized the Appropriate Use Criteria/Clinical Decision Support rules that will be operational as an “Educational and Operations” testing period during 2020. Full implementation in 2021 means that payment to radiologists will be denied for certain advanced imaging services that do not meet the ordering criteria.
The MPFS Final Rule for 2020 finalizes the re-alignment of Evaluation and Management (E/M) codes beginning in 2021 that has the potential to significantly reduce reimbursement to radiologists due to the Medicare program’s budget neutrality provision. Payment for E/M visits will be increased under this rule which means that payment for other areas has to be reduced. Since radiologists bill for relatively few E/M visits, their payment reduction could be on the order of 8% for diagnostic radiology and 6% for interventional radiology, according to the CMS estimates. Other organizations such as the American College of Radiology, put the estimate higher. Watch for updates next year as this policy is being challenged and could be revised.
CMS routinely reviews the valuation of certain procedures for appropriateness in the context of other similar or related procedures. CPT Code 76377 (3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image post-processing under concurrent supervision; requiring image post-processing on an independent workstation) has been identified as potentially mis-valued and will be reviewed during 2020 for possible adjustment.
The MPFS Final Rule is only one aspect of the many changes that take place annually. We have recently issued our review of ICD-10 coding changes and we will soon have a thorough review of the CPT coding changes for 2020, along with our annual analysis of the impact of the specific Medicare fee schedule valuation changes that affect your radiology practice. Subscribe to this blog to be sure you receive these updates and information in other areas of interest that will help you maximize reimbursement in the complicated and ever-changing healthcare realm.
Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners.