On July 29, the Centers for Medicare & Medicaid Services (CMS) published three proposed rules for Calendar Year (CY) 2020:

  • Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule;
  • Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule (MPFS); and
  • End State Renal Disease (ESRD) and Durable Medical Equipment Prosthetics, Orthotics and Supplies (DMEPOS) Proposed Rule.

Public comments to all three proposed rules are due by September 27.

Hospital OPPS and ASC Proposed Rule

The hospital OPPS and ASC proposed rule would increase Medicare OPPS rates by a net 2.7 percent in CY 2020, which update is based on the projected hospital market basket increase of 3.2 percent minus a 0.5 percent adjustment for Multi-Factor Productivity. The rule would also complete the phase-in of the site-neutral rate (40 percent of the OPPS rate) for clinic visits furnished in excepted (grandfathered) off-campus provider-based departments, and continue reductions in payments for certain drugs purchased under the 340B drug discount program to average sales price minus 22.5 percent. The proposed rule would also require hospitals to disclose payer-specific negotiated rates by defining “standard charge” to include payer-specific negotiated rates, in addition to gross charges. Hospitals would also have to publish the negotiated rates for 300 “shoppable” services. CMS also proposes to revise the definition of “hospital” to mean an institution in any State in which State or applicable local law provides for the licensing of hospitals and which is licensed as a hospital pursuant to such law, or is approved by the agency of such State or locality responsible for licensing hospitals as meeting the standards established for such licensing. The proposed rule also would reduce the required level of supervision from direct supervision to general supervision for therapeutic services furnished in hospital and Critical Access Hospital provider-based departments. Regarding ASCs, CMS is proposing to add Total Knee Arthroplasty (TKA) and three coronary intervention procedures to the ASC Covered Procedures List.

The OPPS/ASC proposed rule is available here. A CMS press release and fact sheet are available here and here.

MPFS Proposed Rule

The MPFS proposed rule would update physician fee schedule rates by 0.14 percent in CY 2020 with a conversion factor of $36.09. CMS proposes to revert back to its previous policy of separate payment rates for five levels of evaluation and management (E/M) services for established patients but have four E/M payment levels for new patients. The proposed rule also would permit physicians and certain non-physician practitioners to review and verify, rather than re-document, notes made in the medical record by others. The agency proposes to revise the physician supervision requirement for physician assistants (PAs) to provide that in the absence of State law governing physician supervision of PA services, the physician supervision required would be evidenced by documentation in the medical record of the PA’s approach to working with physicians in furnishing their services. The rule would add the following codes to the list of covered telehealth services: HCPCS codes GYYY1, GYYY2, and GYYY3, which codes describe a bundled episode of care for treatment of opioid use disorders. CMS would also increase the payment for Transitional Care Management (TCM), which is a care management service provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays.

The MPFS proposed rule is available here and a CMS press release and fact sheet are available here and here.

ESRD/DMEPOS Proposed Rule

Under the ESRD/DMEPOS proposed rule, the CY 2020 ESRD PPS base rate would be $240.27, an increase of $5.00. The rule proposes updates to the Acute Kidney Injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI and changes to the ESRD Quality Incentive Program. The rule also proposes a methodology for calculating the fee schedule payment amounts for new DMEPOS items and making adjustments to the fee schedule amounts established using supplier or commercial prices if such prices decrease within five years of establishing the initial fee schedule amounts. The rule would also revise existing policies governing the competitive bidding program for DMEPOS, streamline the requirements for ordering DMEPOS items, and create one Master List of DMEPOS items that could potentially be subject to face-to-face encounter and written order prior to delivery and/or prior authorization requirements.

The ESRD/DMEPOS proposed rule is available here and a CMS press release and fact sheet are available here and here.