The Cognitive Care Alliance, an ad hoc organization led by John Goodson, MD, coordinates several cognitive medical societies to boost the effectiveness of communications with members of Congress and various officials in the CMS. It has worked to convey the negative impact over time as evaluation and management services become increasingly undervalued, “so much so that serious physician workforce shortages and patient access issues were becoming increasingly apparent,” Dr. Laing shares. “Happily, that message was received, and CMS agreed with the increases that were ultimately recommended by the AMA Relative Value Committee. As we await the next final rule from CMS, each of these advocates will continue supporting final rule implementation.”
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Ongoing Advocacy for Complex Care Reimbursement
Advocacy for better valuing the expertise and complex care provided by rheumatologists dates back to 1992 after the CMS adopted the Resource-Based Relative Value System, according to Adam Cooper, MS, senior director of ACR government affairs. In 2010, after the Affordable Care Act became law and included implementation of a primary care bonus, rheumatologists and other cognitive specialists were excluded from receiving the bonus solely because of specialty designation. However, rheumatologists bill the same E/M codes as primary care doctors, primarily provide office visit services and often serve as a principal care provider for their patients.
“The bonus later expired, but the ACR’s advocacy for better recognizing and reimbursing the complex care provided by rheumatologists continued and helped result in the E/M improvements and increases in the 2020 fee schedule final rule,” Mr. Cooper says.
Changes identified in the 2020 Physician Fee Schedule and Quality Payment Program final rule that affect rheumatology include the following:
- A 15% increase for E/M reimbursement for rheumatologists;
- A single complexity add-on code (GPCX1) available to all specialties for visits that are part of ongoing care related to a patient’s single, serious or complex chronic condition;
- Reduced reimbursement for physical therapists, which the ACR opposes on the grounds that the role of occupational and physical therapists should be appropriately valued to protect patient access to these services;
- New care management codes that separate coding and payment for Principal Care Management (PCM) services;
- A policy that allows a physician, resident or nurse to document that the teaching physician was present at the time the service was delivered; and
- An additional Merit-Based Incentive Payment System (MIPS) pathway.
The ACR responded to the final rule to share input, suggestions and concerns regarding implementation of these changes. The 2020 rule does have one important caveat: Changes incorporated in the final rule could still be modified due to provisions in the rule that require changes not to take effect until 2021.