Aug. 8, 2019

Issue Spotlight

Medicare pay should recognize value of surgeons' office visits

Due to budget-neutrality requirements, some surgeons and other physicians may realize overall payment reductions to offset the costs of the Centers for Medicare & Medicaid Services (CMS) recently proposed increases to those who deliver more office visit-based services.

While CMS proposed cutting the administrative burdens many physicians face regarding coding of evaluation and management (E/M) office visit services, some physicians may see their payments reduced in 2021.

Details on these developments are outlined in the proposed 2020 Medicare physician payment schedule, a 1,700-page document that incorporates some of the work done by the AMA-convened Current Procedural Terminology (CPT®) Editorial Panel, which approved revisions to the CPT E/M visit reporting guidelines and code descriptors.

The proposed rule also includes recommendations from the AMA/Specialty Society RVS Update Committee (RUC), which assigns values for the different services physicians provide and the cost of resources needed to furnish those services. Those costs are broken down into relative value units (RVUs).

Impact on surgery follow-ups

CMS generally followed the RUC's recommendations, but there were two notable exceptions.

One is that primary care physicians and other physicians will get an add-on payment for office visits to whom they provide ongoing primary care or who have at least one serious or complex condition. By law, any changes to the payment schedule's RVUs must be budget neutral. The add-on payment will be paid for by redistributing up to $2 billion from the Medicare conversion factor and other physician services.

The other is that while payment will rise for stand-alone office visits in 2021, the visits bundled into the global surgery package will not be increased. CMS has historically increased these bundled visits to be equivalent to the valuation of stand-alone office visits.

The proposed rule notes the meticulous methodology of the RUC surveys and appeared to agree with the panel's recommendation that E/M visits—regardless of the physician's specialty—address complicated matters.

"The RUC recommendations reflect a rigorous robust survey approach, including surveying over 50 specialty societies, demonstrate that office/outpatient E/M visits are generally more complex, for most clinicians," the proposed rule states.

Specialties whose practices rarely have office visits with patients are set to see cuts in 2021. For 2020, a small pay increase for most physicians is expected as the proposed conversion factor is $36.0896, or 5 cents higher per RVU, than it is for 2019.

Concerns regarding the projected 2021 pay cuts for surgeons and other physicians will be included in the AMA's comments on the proposed payment schedule. Comments are due by Sept. 27. By statute, the final Medicare physician fee schedule must be released on or before Nov. 1.

The AMA is hard at work developing educational materials to describe the revised CPT office visit codes and documentation guidelines, which are designed to reduce administrative burdens. Subscribe now to stay in the loop on the latest updates of the AMA's ongoing CPT work.

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National Update

America's physicians demand action on gun violence

The AMA is calling for meaningful action to address the public health crisis of firearms violence. Two more horrific episodes shook the country last weekend with mass shootings in El Paso, Texas, and Dayton, Ohio, that left 31 dead and more than 50 wounded.

"The devastating gun-violence tragedies in our nation this weekend are heartbreaking to physicians across America," AMA President Patrice A. Harris, MD, MA, said in a statement Sunday. "We see the victims in our emergency departments and deliver trauma care to the injured, provide psychiatric care to the survivors and console the families of the deceased. The frequency and scale of these mass shootings demands action."

Nearly 40,000 Americans are killed each year in acts of firearms violence and about 85,000 more are injured, according to the Centers for Disease Control and Prevention. The AMA has been a long-time advocate for violence prevention and, after the 2016 Pulse nightclub shooting in Orlando, Florida, the Association adopted policy declaring that firearms violence is a public health crisis.

Read more on the AMA website and in the Annals of Internal Medicine, where the AMA joined a call to action with 6 of the nation's largest physician professional societies and the American Public Health Association, "Firearm-Related Injury and Death in the United States: A Call to Action from the Nation's Leading Physician and Public Health Professional Organizations."

Surprise billing: 4 points to raise with your members of Congress during recess

Congress is out of session for all of August, but there are opportunities for physicians to engage senators and representatives as they hold town halls and do other work back in their home districts. American physicians should know about the consequential legislation that has advanced on surprise medical bills and keep four key points in mind when raising the issue with their elected representatives in Congress during the August recess.

Physicians and others agree on this central tenet: Patients should be held harmless and not subject to bills higher than they would expect to pay had an in-network physician been available and there should be a fair system to resolve payment disputes between insurers and physicians.

Read more, including other key points to make with your congressional representatives, and access an action kit.

FDA unveils new drug importation plan

On July 31, the Trump administration announced new steps towards allowing the importation of certain drug products into the United States from foreign countries. An attempt to help ease pricing pressures on American patients, the Safe Importation Action Plan would allow two potential pathways for importation—one authorizing demonstration projects to allow importation from Canada by states, wholesalers or pharmacies and one allowing importation by manufacturers that sell any drug in foreign countries, so long as the drug is the same as the U.S.-approved version. The administration plans to release a Notice of Proposed Rulemaking, as well as draft guidance to begin implementation of the new plan in the coming months.

The AMA has supported safe importation of drugs from other countries in certain circumstances to help source drugs that routinely have much lower prices in other countries. The administration's plan has been met with some skepticism, such as concerns in Canada about the potential impact on its drug supply and the exacerbation of drug shortages. Other concerns have been raised about the second pathway, with some saying it will allow drug manufacturers to avoid the current rebate system and work around current pharmacy benefit manager contacts without assurance of meaningful impact on drug list prices for American patients. The AMA is monitoring the development of this pathway and continues to work closely with the administration and Congress to find a path forward towards lower drug prices and out-of-pocket costs for patients.

CMS to score tobacco use measure as pay-for-reporting in the 2018 MSSP

As a result of concerns raised by the AMA and other organizations about substantive changes to the Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention measure (PREV-10/ACO-17) that is part of the 2018 Medicare Shared Savings Program (MSSP), the CMS has reclassified the measure as pay-for-reporting under the 2018 Shared Savings Program quality scoring methodology. The measure underwent substantive changes between 2017 and 2018 by eliminating the inclusion of non-tobacco users from the calculation of the performance score and as a result impacted scoring.

Additionally, the 2018 measure specification for the CMS Web Interface PREV-10 measure provided new guidance in a footnote that the timing of the tobacco cessation intervention had to occur during or after the most recent positive screen for tobacco use. Due to AMA advocacy, CMS has determined that the previously stated guidance is inconsistent with the intent of the CMS Web Interface version of this measure and substantive in nature. 

For Merit-based Incentive Payment System (MIPS) alternative payment model (APM) participants subject to the APM scoring standard, the measure will be excluded from 2018 MIPS performance period score and will not contribute to their MIPS quality performance category score.  Please note, this change only applies to the CMS Web Interface version of the measure and does not apply to any other collection type. Measure ACO-17 is also reported in MIPS as Measure 226. Therefore, the AMA will continue to advocate for the need for similar scoring accommodations for clinicians who reported the measure in 2018 MIPS through other collection types. The AMA does not believe CMS' policy of creating a benchmark based on the performance period sufficiently addresses the issue given the change was not clearly communicated at the start of the 2018 performance period.

For more information visit the Quality Payment Program resource library to view the 2018 CMS Web Interface measure specifications.

Physicians can contact the Quality Payment Program with any questions at or 1-866-288-8292 (TTY: 1-877-715-6222).

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Other News

Upcoming MIPS cost measure development webinars

CMS is developing five new episode-based cost measures, including the first chronic condition measures, for potential use in MIPS. In response to the AMA's requests, CMS and its contractor, Acumen LLC, have made the upcoming measure development meetings open to interested specialty societies and other stakeholders via webinar. These meetings convene physicians to provide input about measure specifications, including measure scope, patient attribution and exclusions.

To register, click on the meeting(s) you are interested in listening to:

For background about the MIPS cost measure development process, visit the Medicare Access and CHIP Reauthorization Act feedback page.

ONC spotlights AMA digital health implementation playbook

The Office of the National Coordinator for Health Information Technology (ONC) recently updated its Health IT Playbook to include an AMA-developed implementation guide to help physicians adopt and use digital health technology in their practice. ONC's Health IT Playbook is an easy-to-navigate resource designed by and for physicians.

AMA's Digital Health Implementation Playbook complements ONC's efforts by offering key steps, best practices and resources to accelerate the adoption and scale of remote patient monitoring services. The addition of the Digital Health Playbook continues ONC's recognition of AMA-developed tools, such as EHR STEPS Forward modules, as important resources for physicians.

Rx Drug Abuse & Heroin Summit submission deadline is Aug. 23

The Rx Drug Abuse & Heroin Summit is now accepting submissions for the 2020 meeting, taking place April 13-16 in Nashville, TN. The Rx Drug Abuse & Heroin Summit is the largest national collaboration of professionals from local, state and federal agencies, business, academia, clinicians, treatment providers, counselors, educators, state and national leaders, law enforcement/public safety, and advocates impacted by the opioid crisis. The summit will be accepting presentation proposals that accommodate the following formats:

  • Breakout sessions (75 minutes, including a question and answer segment)
  • Posters (which will be featured in the exhibit hall and have designated poster presentation times where presenters will be required to stand by their posters)

The presentations should be tailored to provide stakeholders timely and relevant information for their particular fields. Submissions will be reviewed by the Rx Summit's National Advisory Board members, who represent multi-disciplinary interests. Submissions are due by Aug. 23 11:59 p.m. Eastern time. Submissions should be submitted here.

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Upcoming Events

Register now for 2020 AMA advocacy conferences and save 20%

The 2020 AMA State Advocacy Summit will be held in Bonita Springs, Florida, at the Hyatt Regency Coconut Point Resort and Spa, Jan. 9-11. The 2020 AMA National Advocacy Conference will be held in Washington, D.C., at the Grand Hyatt, Feb. 10-12. Register now for both meetings and save 20%.

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