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Rules, Rules, Rules: What You Need to Know About the Latest from CMS

Sep 05, 2019

Regulatory requirements can be overwhelming. AAPM&R advocates to represent the interests of you and the patients you serve. Plus, your membership gives you access to information and updates so that you can avoid penalties, maximize reimbursement, and focus on what matters—your patients.

The updates below focus on recent proposed and finalized rules from the Centers for Medicare and Medicaid Services to understand how physiatrists will be affected. 

Proposed Rules

2020 Physician Fee Schedule (PFS) Proposed Rule

  • CMS has rescinded its proposal to collapse payment for level 2-4 office/outpatient E/M visits. Instead, CMS proposes implementing revised office/outpatient E/M coding and documentation guidelines as well as payment increases for most office/outpatient E/M codes, effective January 1, 2021. Read more.
  • CMS proposes to implement payment for 4 new codes describing injections and destruction/ablation of the genicular nerve branches and the nerves innervating the sacroiliac joint. Read more.
  • CMS proposes to implement payment for 2 new dry needling codes.
  • CMS proposes to redefine the physician supervision requirement for services delivered by a physician assistant (PA). The new requirement will conform to state law and state scope of practice rules for PAs in the state in which the services are furnished.
  • AAPM&R is in the process of commenting on all issues listed above. Review the first of your Academy’s comment letters on this rule. Additional comments on the rule will be posted later this month.

Quality Payment Program (QPP)

  • CMS solicits feedback on creating a new MIPS Value Pathways (MVP) program to take effect in 2021. The program would allow more cohesive participation based on the participant’s specialty or medical condition they treat. Read more.
  • CMS proposes to remove the Pain Assessment and Follow-Up measure for the 2020 MIPS performance year. This is 1 of 55 measures CMS is proposing to remove from MIPS this year.
  • CMS proposes changes to the attribution criteria for the total per capita cost and Medicare spending per beneficiary cost measures.
  • The MIPS performance threshold is proposed to increase from 30 points in 2019 to 45 points in 2020 with the exceptional performance threshold being 80 points for 2020. In 2020, performance will be based on Quality (40%), Cost (20%), Promoting Interoperability (25%) and Improvement Activities (15%). Read more.

A final rule is expected in November 2019.

2020 Outpatient Prospective Payment System (OPPS) and ASC Payment System Proposed Rule

  • CMS proposes a 2.7% increase to the OPPS conversion factor for 2020 ($81.398).
  • CMS proposes adding to the OPPS the 4 new codes describing injections and destruction/ablation of the genicular nerve branches and the nerves innervating the sacroiliac joint.
  • Following up on proposals finalized last year, CMS is continuing to push for site-neutral payment in off-campus provider-based departments. In 2020, CMS proposes to pay at 40% the OPPS rate for services provided in these settings to achieve more consistency with PFS rates for services. Read more.
  • In an effort to increase hospital price transparency, CMS proposes a new requirement that hospitals make public their standard charges for all items and services.
  • AAPM&R is in the process of developing comments on the OPPS proposed rule.

A final rule is expected in November 2019.

2020 Home Health Prospective Payment System Proposed Rule

  • CMS describes implementation of the Patient-Driven Groups Model, which is a revised case-mix adjustment methodology which was finalized in the CY 2019 final rule for implementation beginning January 1, 2020. Read more.

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Final Rules

2020 Skilled Nursing Facility (SNF) Prospective Payment System (PPS) Final Rule

  • The Patient Driven Payment Model (PDPM) is replacing the Resource Utilization Groups, version IV as of October 1, 2019. The PDPM is a more specific analysis of patient condition and needs for different therapies, which will indicate payment level. The patient payment to the facility can change over time. The PDPM is tied to how much is spent on a patient each day. Read more.
  • CMS is finalizing its revision to the definition of group therapy as proposed without modification. Under the SNF PPS, group therapy will be defined as a qualified rehabilitation therapist or therapy assistant treating 2 to 6 patients at the same time who are performing the same or similar activities. Read more.

Unless otherwise noted, policies in the rule are effective October 1, 2019. 

2020 Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS) Final Rule

  • CMS finalized its proposal to amend existing regulations to clarify that the determination as to whether a physician qualifies as a rehabilitation physician (that is a licensed physician with specialized training and experience in inpatient rehabilitation) is made by the IRF. Read our comments to the IRF PPS proposed rule on this issue. Read the AAPM&R-led sign-on letter responding to the IRF PPS proposal of this amendment.
  • CMS did not respond to our questions related to resident capabilities in IRFs. Read our original letter to CMS regarding this issue.
  • Prior authorization and burdensome paperwork were not addressed. Review several AAPM&R communications to CMS regarding these issues.
  • Claims denials were not acknowledged outside of CMS acknowledging our comments on the definition of rehabilitation physician – stating that “[s]ome commenters also stated that clarifying the regulation would reduce the number of claims denials by promoting a shared understanding of the requirements between IRFs and Medicare contractors.”

Unless otherwise noted, policies in the rule are in effect October 1, 2019. 

Quality Reporting Program (QRP) for SNF and IRF

  • CMS adopted two process measures, the Transfer of Health Information to the Provider – PAC Measure and the Transfer of Health Information to the Patient – PAC Measure. Effective FY 2022.
  • CMS finalized its proposal to exclude baseline nursing facility residents form the Discharge to Community-PAC IRF QRP measure.
  • CMS finalized the new standardized patient assessment data elements (SPADEs) that IRFs would be required to report. These will be standardized patient assessment data beginning FY 2022.
  • CMS finalized its proposal to adopt a pain interference (pain effect on sleep, pain interference with therapy activities, and pain interference with day-to-day activities) data element as standardized patient assessment data. Read more.
  • CMS will deem SNFs that submit the Hearing, Vision, Race, Ethnicity, Preferred Language, and Interpreter Services Standardized Patient Assessment Data Elements (SPADEs) with respect to admission to have submitted with respect to admission and discharge.
  • CMS collected information on a new category of SPADEs – Social Determinants of Health (SDOHs) related to race, ethnicity, preferred language, interpreter services, health literacy, transportation, and social isolation. All of these were adopted.

Unless otherwise noted, policies in the rule are in effect October 1, 2019. 

2020 Inpatient Prospective Payment System (IPPS) Final Rule

Quality Reporting Program (QRP)

  • CMS adopted for 2021 reporting/FY 2023 payment the Safe Use of Opioids – Concurrent Prescribing eCQM (NQF #3316e), which focuses on concurrent prescriptions of opioids and benzodiazepines at discharge. It opted not to adopt the Hospital Harm – Opioid-Related Adverse Events eCQM, designed to reduce adverse events associated with the administration of opioids in the hospital setting by assessing the administration of naloxone as an indicator of harm.
  • CMS also decided to adopt a Hybrid Hospital-Wide Readmission (HWR) Measure that relies on claims and EHR data. This measure would be voluntary starting in 2021 and mandatory starting in July 2023.
  • CMS also provided an update on its efforts to confidentially report hospital quality measure data stratified by social risk factors and to educate stakeholders on these data. Read more.
  • Long-Term Care Health Quality Reporting Program: CMS largely finalized its policies as proposed, including the addition of new IMPACT Act Transfer of Health Information measures, addition of new standardized patient assessment data elements (SPADEs), and establishment of a new category of SPADEs focused on social determinants of health. These policies largely align with policies finalized for the IRF and SNF Quality Reporting Programs.

Unless otherwise noted, policies in the rule are in effect October 1, 2019.