2020 Physician Fee Schedule Proposed Rule

1. 2020 Physician Fee Schedule Proposed Rule

2. CY 2020 PFS Conversion Factor • CY 2020 PFS conversion factor: $36.09 • Currently $36.04

3. Medicare Telehealth Services • HCPCS code GYYY1: Office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month.

4. Medicare Telehealth Services • HCPCS code GYYY2: Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month.

5. Medicare Telehealth Services • HCPCS code GYYY3: Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (List separately in addition to code for primary procedure).

6. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • Opioid agonist and antagonist treatment medications (including oral, injected, or implanted versions) that are approved by the Food and Drug Administration (FDA) under section 505 of the Federal Food, Drug, and Cosmetic Act (FFDCA) (21 U.S.C. 355) for use in the treatment of OUD; • Dispensing and administration of such medications, if applicable; • Substance use counseling by a professional to the extent authorized under state law to furnish such services;

7. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • Individual and group therapy with a physician or psychologist (or other mental health professional to the extent authorized under state law); • Toxicology testing; and • Other items and services that the Secretary determines are appropriate (but in no event to include meals or transportation).

8. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXXX1: Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program).

9. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXXX2: Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program).

10. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXXX3: Medication assisted treatment, buprenorphine (injectable); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program).

11. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXXX4: Medication assisted treatment, buprenorphine (implant insertion); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program).

12. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXXX5: Medication assisted treatment, buprenorphine (implant removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program).

13. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXXX6: Medication assisted treatment, buprenorphine (implant insertion and removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program).

14. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXXX7: Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program).

15. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXXX8: Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program).

16. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXXX9: Medication assisted treatment, medication not otherwise specified; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program).

17. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXX10: Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program); partial episode. Do not report with GXXX1.

18. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXX11: Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program); partial episode. Do not report with GXXX2.

19. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXX12: Medication assisted treatment, buprenorphine (injectable); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program); partial episode. Do not report with GXXX3.

20. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXX13: Medication assisted treatment, buprenorphine (implant insertion); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program); partial episode (only to be billed once every 6 months). Do not report with GXXX4

21. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXX14: Medication assisted treatment, buprenorphine (implant removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program); partial episode. Do not report with GXXX5

22. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXX15: Medication assisted treatment, buprenorphine (implant insertion and removal); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program); partial episode. Do not report with GXXX6

23. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXX16: Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program); partial episode. Do not report with GXXX7.

24. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXX17: Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program); partial episode. Do not report with GXXX8.

25. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXX18: Medication assisted treatment, medication not otherwise specified; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program); partial episode. Do not report with GXXX9.

26. Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs) • HCPCS code GXX19: Each additional 30 minutes of counseling or group or individual therapy in a week of medication assisted treatment, (provision of the services by a Medicare enrolled Opioid Treatment Program); List separately in addition to code for primary procedure.

27. Physician Supervision Requirements for Physician Assistants (PAs) • Currently requires general supervision • Proposal: follow state law and state scope of practice rules for PAs

28. Review and Verification of Medical Record Documentation • Extent of the teaching physician’s participation in services involving residents may be demonstrated by notes in the medical records made by a physician, resident, or nurse

29. Care Management Services • Propose to revise billing restrictions and allow submission of transitional care management with the following codes: • 99358, 99359, 93792, 93793, 90960, 90961, 90962, 90966, 90970, 90991, 99487, 99489, G0181, and G0182

30. Care Management Services • Propose two new HCPCS codes for chronic care management • HCPCS code GCCC1 (Chronic care management services, initial 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; and comprehensive care plan established, implemented, revised, or monitored. (Chronic care management services of less than 20 minutes duration, in a calendar month, are not reported separately)).

31. Care Management Services • Propose two new HCPCS codes for chronic care management • Add-on HCPCS code GCCC2 (Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).

32. Care Management Services • Propose two new HCPCS codes for complex chronic care management • HCPCS code GCCC3 (Complex chronic care management services, with the following required elements: Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient; chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored; moderate or high complexity medical decision making; 60 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month. (Complex chronic care management services of less than 60 minutes duration, in a calendar month, are not reported separately)).

33. Care Management Services • HCPCS code GCCC4 (each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure).

34. Care Management Services • Define comprehensive care plan • Problem list. • Expected outcome and prognosis. • Measurable treatment goals. • Cognitive and functional assessment. • Symptom management.

35. Care Management Services • Define comprehensive care plan • Planned interventions. • Medical management. • Environmental evaluation. • Caregiver assessment. • Interaction and coordination with outside resources and practitioners and providers. • Requirements for periodic review. • When applicable, revision of the care plan.

36. Care Management Services • Two New Principal Care Management (PCM) Services • HCPCS code GPPP1 (Comprehensive care management services for a single highrisk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities)

37. Care Management Services • HCPCS code GPPP2 (Comprehensive care management for a single high-risk disease services, e.g., Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities).

38. Comment Solicitation on Opportunities for Bundled Payments under the PFS • CMS is exploring the extent to which these basic principles of bundled payment, such as establishing per beneficiary payments for multiple services or condition-specific episodes of care, can be applied within the statutory framework of the PFS.

39. Therapy Services • Propose to add a new paragraph (e)(1)(v) to §§ 410.59 and 410.60 to clarify that the specified amounts of annual per beneficiary incurred expenses are no longer applied as limitations but as threshold amounts above which services require, as a condition of payment, inclusion of the KX modifier

40. Evaluation and Management Accept the AMA new and established E/M changes effective January 1, 2021

41. Evaluation and Management New and established codes selected based on a new defined MDM or Time

42. Evaluation and Management Remove history and exam as key components

43. Evaluation and Management Time redefined from face-to-face time to total time spent on the day of the encounter • Defined total time • Guideline added to clarify when more than one provider is involved

44. Evaluation and Management Preparing to see the patient (eg, review of tests) Obtaining and/or reviewing separately obtained history Performing a medically appropriate examination and/or evaluation Counseling and educating the patient/family/caregiver Documenting clinical information in the electronic or other health record Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver Care coordination (not separately reported)

46. Evaluation and Management Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services) (Use 99XXX in conjunction with 99205, 99215) (Do not report 99XXX in conjunction with 99354, 99355, 99358, 99359, 99415, 99416) (Do not report 99XXX for any time unit less than 15 minutes)

47. Evaluation and Management Revision of MDM definitions • Number and Complexity of Problems Addressed • Amount and/or Complexity of Data to be Reviewed and Analyzed • Risk of Complications and/or Morbidity or Mortality of Patient Management

48. Evaluation and Management Elimination of 99201

49. Evaluation and Management Considering new add-on codes for primary care and other non-procedural specialized medical care

50. Evaluation and Management Proposed HCPCS Level II Code Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. (Addon code, list separately in addition to office/ outpatient evaluation and management visit, new or established)