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Home Advocacy Comment Letters & Resources Physician Payment and Coverage Issues Proposed 2020 Rule for the Medicare Physician Fee Schedule and the Quality Payment Program

Proposed 2020 Rule for the Medicare Physician Fee Schedule and the Quality Payment Program

On July 29, 2019, the Centers for Medicare & Medicaid Services (CMS) released the CY 2020 Medicare Physician Fee Schedule and Quality Payment Program proposed rule. The AUA submitted its comment letter to CMS on September 24.

Although the letter provided comments on many changes in the rule, the tables below highlight key topics in our comments:

2020 Proposed Medicare Fee Schedule
What CMS Proposed in the Rule and How the AUA Responded:
Conversion Factor

CMS Proposes: A $0.05 increase in the conversion factor over 2019, with a 2020 conversion factor of $36.09.
AUA Position: Support

Specialty Impact

CMS Proposes: CMS estimates that the proposed Fee Schedule changes will result in an increase of 1 percent in allowable charges for urology (overall 0 percent increase in work RVUs and a 1 percent increase in practice expense RVUs).
AUA Position: Support

Evaluation & Management (E/M) Coding

CMS Proposes: : Implement the revised E/M code definitions developed by the AMA CPT Editorial Panel earlier this year that have an effective date of January 1, 2021 and not implement the consolidation of E/M codes as planned. According to the agency’s calculations, the E/M changes included in the rule would lead to an 8 percent increase for urology.
AUA Position: Support

E/M Payments

CMS Proposes: Retain separate payment for individual E/M services as revised by the CPT Editorial Panel, including the adoption of values for the new patient outpatient service office visit CPT codes (99202-99205) and established patient outpatient codes (99211-99215). Eliminate CPT code 99201. CMS proposes to adopt all of the RUC-recommended work RVUs and times for the revised code family and new prolonged add-on code that were based on a survey of over 50 specialty societies.
AUA Position: Support

Global Surgical Packages

CMS Proposes: Reject the RUC’s recommendation to apply the outpatient E/M visit increases to the 10- and 90-day global services.
AUA Position: Oppose
The AUA urges CMS to apply the RUC recommended E/M changes to the global codes in the place of the agency’s original proposal. We believe the agency must apply these updated E/M values to the global codes or there will be unintended consequences, such as disruption to the relativity of the fee schedule; creation of specialty differentials, violation of the Medicare Access and CHIP Reauthorization Act (MACRA) §523(a). A rejection of the RUC proposal ignores recommendations endorsed by nearly all medical specialties.

Physician Supervision Requirements for Physician Assistants

CMS Proposes: Revise the physician supervision requirement for PA services under Medicare. Specifically, CMS proposes to grant PAs the flexibility to practice in accordance with state law requirements rather than the current general supervision requirement. In the absence of a state law, CMS proposes that the physician supervision requirement be met by “documentation in the medical record of the PA’s approach to working with physicians in furnishing their services.”
AUA Position: Oppose
The AUA believes that CMS’ proposal would create unnecessary variation in standards for care furnished by PAs, based on differences in states’ laws that we believe would not be appropriate for a federal program. We recommend that CMS not finalize this policy and instead retain the general supervision requirement that is currently in place.

Read our blog post for more detailed information about E/M payments under the 2020 proposed fee schedule rule.

 

Quality Payment Program and Merit-based Incentive Payment System Proposed Changes
What CMS Proposed in the Rule and How the AUA Responded:
MIPS Value Pathways initiative

CMS Proposes: A new MIPS Value Pathways (MVP) framework that would connect measures and activities across the 4 MIPS performance categories (Quality, Cost, Improvement Activities and Promoting Interoperability) to be implemented in 2021.
AUA Position: Oppose
We do not support making MVPs mandatory, and instead urge CMS to consider piloting the MVP program and provide an incentive, such as automatically being named an exceptional performer, for participation.

MIPS Performance Thresholds

CMS Proposes: Increase the performance threshold from 30 points in 2019 to 45 points in 2020 and 60 points in 2021. In order to meet the requirements, set out by Congress for the sixth year of the program, the agency also proposed to increase the additional performance threshold for exceptional performance to 80 points in 2020 and to 85 points in 2021.
AUA Position: Oppose
We believe the proposal to increase the performance threshold for the 2022 performance year to 45 points and 60 points in the 2023 performance year will further discourage providers to report on new Quality measures.

Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey Expansion

CMS Proposes: Expanding the CAHPS survey for MIPS for those participating individually.
AUA Position: Support
The AUA recommends CMS allow certain questions be scored pass/fail rather than establishing a new scoring system or benchmarks. Pass/fail scoring will recognize that the true value of certain questions is the collection of patient feedback itself.

 

In addition to changes to the above programs and policies, the proposed rule also includes changes in valuation for a number of services. The AUA made specific comments on the codes below.

Valuation of Specific Urology Services
What CMS Proposed in the Rule and How the AUA Responded:
CPT 64561 – SA022 Kit
(Practice Expense)

CMS Proposes: Recommended price of $114.52
AUA Position: Oppose
Recommends that CMS revisit the recommended price for CPT Code 64561-SA022 (Kit, percutaneous neuro. test stimulation) and use the current invoice price to establish the proper reimbursement for the percutaneous neurostimulation kit

Drug Delivery Implant Procedures
CPT 11980

CMS Proposes: Implementing RUC recommendations that the value and total time are unchanged, and no practice expense refinements are needed.
AUA Position: Support

CPT 11981

CMS Proposes: Contrary to RUC recommendations, CMS is proposing a work RVU of 1.14, but accepting the survey recommendations for time. The agency used CPT code 67500 (Injection of medication into cavity behind eye) with 1.18 work RVUs with 5 minutes of intraservice time and 30 minutes of total time to propose this value. No practice expense time refinements are proposed.
AUA Position: Oppose
The AUA urges CMS to accept the RUC recommended work RVU of 1.30, imploring the agency to independently review the surveyed time and work and not compare it to invalidated sources of the current time and work.

CPT 11982

CMS Proposes: Contrary to RUC recommendations, CMS is proposed a work RVU of 1.34, but is accepting the RUC-recommended times. The agency used CPT code 64486 (Injections of local anesthetic for pain control and abdominal wall analgesia on one side) (work RVU = 1.27, 10 minutes intraservice time and 35 total minutes)) for reference.
AUA Position: Oppose
The AUA urges CMS to accept the RUC recommended work RVU of 1.70, imploring the agency to independently review the surveyed time and work and not compare it to invalidated sources of the current time and work.

CPT 11983

CMS Proposes: Contrary to RUC recommendations, CMS is proposing proposes a work RVU of 1.91 but accepting the RUC-recommended times.
AUA Position: Oppose
The AUA urges CMS to accept the RUC recommended work RVU of 2.10, imploring the agency to independently review the surveyed time and work and not compare it to invalidated sources of the current time and work.

Cystourethroscopy Insertion Transprostatic Implant
CPT 52441

CMS Proposes: Contrary to RUC recommendations, CMS is proposing a work RVU of 4.00. The agency’s proposed valuation is based on crosswalk to CPT code 58562 (Hysterscopy, surgical; with removal of impacted foreign body) that is 4.00 work RVUs and has identical intraservice time.
AUA Position: Oppose
The AUA urges CMS to accept the RUC recommended work RVU of 4.50.

CPT 52442

CMS Proposes: Contrary to RUC recommendations, CMS is proposing 1.01 work RVUs. CMS’ proposal is based on a crosswalk from CPT 36218 [(Selective catheter placement, arterial system; additional second order, third order, and beyond, thoracic or brachiocephalic branch, within a vascular family (List in addition to code for initial second or third order vessel as appropriate),] which has identical intraservice time.
AUA Position: Oppose
The AUA urges CMS to accept the RUC recommended work RVU of 1.20.

Orchiopexy CPT 54640

CMS Proposes: Accepting the RUC-recommended value of 7.73 work RVUs and the direct PE inputs, and the CPT Editorial Panel’s indication that hernia repair is separately reportable with this service.
AUA Position: Support

Urography CPT 74425

CMS Proposes: Accepting the RUC-recommended work RVU of 0.51, total time of 24 minutes, and the direct PE inputs.
AUA Position: Support

Biofeedback Training
CPT 908XX

CMS Proposes: Accepting the RUC-recommended work RVU of 0.90. The agency is proposing to refine the equipment time for the power table (EF031) equipment code included in the service.
AUA Position: Support

CPT 909XX

CMS Proposes: Accepting the RUC-recommended work value of 0.50 RVUs, and designating these services as “sometimes therapy” procedures, which means that an appropriate therapy modifier is always required when billed by therapists.
AUA Position: Support

About the Proposed Rule

View the AUA’s easy reference on how the proposed rule would affect urology offices. The charts below show the effect of the 2020 Fee Schedule on some of the most utilized CPT codes by urologists in the facility and non-facility setting.

The charts below show the effect of the 2020 Medicare Physician Fee Schedule on some of the most utilized CPT codes by urologists in the facility and non-facility setting.

Facility Non-Facility
2020 MPFS Final Rule Conversion Tables Facility 2020 MPFS Final Rule Conversion Tables Non-Facility

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