CMS' final outpatient, physician payment rules for 2020: 9 things to know

CMS released final rules Nov. 2, which include payment updates for outpatient and physician services and delay action on a proposed price transparency initiative.

Here are nine takeaways from the final rules:

Medicare Outpatient Prospective Payment System

1. Payment update. CMS is increasing OPPS rates by 2.6 percent in 2020 compared to 2019.

2. Site-neutral payments. CMS will finish phasing in a policy adopted in 2018 to make payments for clinic visits site-neutral by reducing the payment rate for hospital outpatient clinic visits provided at off-campus provider-based departments. These off-campus departments will be paid at a rate of 40 percent of the OPPS rate in 2020.

CMS moved forward with the cuts after a Washington, D.C., federal court ruled Sept. 17 that CMS overstepped its authority when it expanded the site-neutral pay policy. CMS said it is considering "whether to appeal from the final judgment."

Regarding the changes, AHA Executive Vice President Tom Nickels said: "The final rule's continued payment cuts for hospital outpatient clinic visits not only threatens access to care, especially in rural and other vulnerable communities, but it goes against clear congressional intent to protect the majority of clinic services." He continued, "Now that a federal court has sided with the AHA and found that these cuts exceed the Administration's authority, CMS should abandon further illegal cuts."

3. 340B program. CMS will continue its policy of paying hospitals 22.5 percent less than the average sales price for certain drugs purchased through the 340B program. The AHA, other hospital associations and several hospitals successfully challenged previous cuts to the 340B program in court.

4. Prior authorization. Beginning July 1, 2020, CMS will implement a prior authorization process for the following categories of hospital outpatient department services: blepharoplasty, botulinum toxin injections, panniculectomy, rhinoplasty and vein ablation.

5. Price transparency. CMS said it will issue a separate final rule regarding a proposal that hospitals disclose payer-specific negotiated rates. The proposal, issued in July, would require hospitals to publish payer-specific negotiated rates for 300 services consumers are likely to shop for, including 70 defined by CMS, in a searchable and consumer-friendly manner. Hospitals that fail to publish the prices could be fined up to $300 a day.

Access the 2020 Medicare Outpatient Prospective Payment System final rule here.

Medicare Physician Fee Schedule

6. Payment update. After applying the budget-neutrality adjustment required by law, the 2020 Physician Fee Schedule conversion factor is $36.09, up from $36.04 in 2019.

7. Evaluation and management coding and payment. The final rule sets separate payment rates for all five levels of coding for evaluation and management visits.

8. Medical record documentation. The final rule allows physicians, physician assistants, and advanced practice registered nurses to review and verify information in a patient's medical record that is entered by other clinicians, rather than re-entering the information.

9. Telehealth services. CMS will add a set of codes, which describe a bundled episode of care for treatment of opioid use disorders, to the list of telehealth services covered by Medicare.

Access the 2020 Medicare Physician Fee Schedule final rule here.

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