CMS Releases Final 2020 Medicare Physician Fee Schedule and Hospital Outpatient Rules

The Centers for Medicare and Medicaid Services (CMS) has released the 2020 Medicare Physician Fee Schedule final rule addressing Medicare payment and quality provisions for physicians in 2020. Under the proposal, physicians will see a virtually flat conversion factor on Jan. 1, 2020, going from $36.04 to $36.09. CMS estimates that the physician rule will maintain overall payment to cardiologists from 2019 to 2020 through updates to work, practice expense, and malpractice RVUs. This estimate is based on the entire cardiology profession and can vary widely depending on the mix of services provided in a practice.

The Physician Fee Schedule was released in tandem with the 2020 Hospital Outpatient Prospective Payment System final rule. The outpatient rule indicates a 2.6 percent payment update for hospitals and other proposals. Highlights from both proposed rules include: 

Physician Fee Schedule

  • Significant payment cuts to myocardial PET were not finalized. After significant advocacy efforts by ACC and partner stakeholders, CMS revised the inputs used to calculate technical component payment for myocardial PET services. Rather than facing technical component cuts as high as 80 percent, the technical component of myocardial PET services will continue to be paid contractor pricing in 2020 while additional information about direct practice expense inputs is developed for future rulemaking. ACC and others will provide additional information as feasible to further inform ratesetting. CMS also altered its proposal on physician work, adopting AMA Relative Value Scale Update Committee (RUC) recommendations rather than proposed lower alternatives.
  • After proposed changes to evaluation and management (E/M) payment were both altered and/or delayed until 2021 in the 2019 final rule last November, in this rule CMS finalized revisions to E/M documentation and payment policies.
    • Walking back a prior plan to pay a blended rate for level 2-4 visits, CMS has adopted revised E/M code definitions developed by the AMA CPT Editorial Panel starting Jan. 1, 2021. Members from across the House of Medicine worked together throughout the process to address concerns about documentation burden in a manner that was less disruptive and correctly discerned differences in levels of E/M services.
    • The revised coding definitions is paired with a decision to pay for each level of service rather than use a blended rate.
    • Incorporating recommendations from the AMA RUC, CMS adopted revised work and practice expense (PE) inputs for E/M services.
  • CMS made no changes regarding implementation of the mandate requiring that clinicians consult appropriate use criteria (AUC) through a qualified clinical decision support mechanism (CDSM) starting Jan. 1, 2020, when ordering advanced imaging services (i.e., SPECT/PET MPI, CT and MR). Requirements were recently summarized in this MLN Matters article. Additional resources are available at
  • CMS made updates to work and/or PE values for codes describing transcatheter aortic valve replacement (TAVR), remote loop recorder interrogation and remote cardiac monitor interrogation, noncoronary intravascular ultrasound (IVUS), and abdominal aortography. More detail will be available after CMS posts supporting data tables.
  • Work and or PE values for new/revised codes describing self-measured blood pressure monitoring, ambulatory blood pressure monitoring, remote physiologic monitoring, pericardiocentesis and pericardial drainage, myocardial strain imaging, and myocardial PET, were included in the final rule.

An additional CMS fact sheet about the PFS is available here.

2020 Quality Payment Program Performance Period

  • Increase in the performance threshold from 30 points in 2019 to 45 points in 2020.
  • Additional increase for exceptional performance to 85 points in 2020.
  • The Quality performance category is weighted at 45% (no change from 2019)
  • The Cost performance category is weighted at 15% (no change from 2019)
  • The Promoting Interoperability performance category is weighted at 25% (no change from 2019)
  • The Improvement Activities performance category is weighted at 15% (no change from 2019)
  • Finalized the revised total per capita cost (TPCC) and the Medicare Spending Per Beneficiary (MSPB) measures.
  • Increase in the data completeness threshold for the quality data that clinicians submit to 70%.
  • Increase in the threshold for clinicians who complete or participate in the Improvement Activity for group reporting.
  • Updates to requirements for Qualified Clinical Data Registry (QCDR) measures and the services that third-party intermediaries must provide (beginning with the 2021 performance period).
  • Initial aspects of the MIPS Value Pathways (MVPs) will commence in the 2021 MIPS performance period, including the extent of first year implementation or the feasibility of an initial pilot. CMS envisions an initial uniform set of Promoting Interoperability measures in each MVP and will consider customizing MVP Promoting Interoperability measures in future years.
  • Maintaining low-volume threshold, eligible clinician types, MIPS performance periods, CEHRT requirements, and small practice bonus points.

An additional CMS QPP fact sheet is available here.

Hospital Outpatient Rule

  • CPT codes describing angioplasty and stent PCI were added to the Ambulatory Surgery Center Covered Procedures list for 2020, reflecting feedback of ACC and other stakeholders.
  • MS finalized operational implementation schedule for prior authorization for July 1, 2020 for certain Outpatient Department Services. Several vein ablation services provided to cardiovascular patients were included on this list.
  • Rather than finalize an earlier proposal requiring hospitals to publicize a list of standard charges, CMS will summarize and respond to concerns about hospitals price transparency for “shoppable” services in forthcoming final rules.
  • MS finalized its proposed APC assignment of cardiac CT angiography and cardiac MRI despite comments indicating these rates undervalue the resources needed to provide these services. APC assignment of FFRCT was altered from APC 1509 with a payment rate of $750.50 to APC 1511 with a payment rate of $950.50.
  • While navigating a lawsuit over this policy, CMS finalized the second of a two-year phase in to cap payment for off-campus hospital clinic visits at a rate equivalent to the physician fee schedule rate.

An additional CMS OPPS fact sheet is available here.

ACC staff are reviewing the rules to identify additional topics of interest to members. More information will be forthcoming in the Advocate newsletter and on in the coming weeks.

Coming to ACC’s 2019 Legislative Conference? ACC Advocacy leaders and staff will discuss federal legislative and regulatory topics on Nov. 4, prior to heading to Capitol Hill to meet with lawmakers and their staff members.

Clinical Topics: Noninvasive Imaging, Computed Tomography, Nuclear Imaging

Keywords: ACC Advocacy, Medicaid, Accountable Care Organizations, Medicare, Fee Schedules, Health Expenditures, Electronic Health Records, Patient Care, Positron-Emission Tomography

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