The Centers for Medicare and Medicaid Service (CMS) placed the Calendar Year 2020 Medicare Physician Fee Schedule Proposed Rule on display at the Federal Register on July 29. Proposed changes to the rule reflect recommendations made by the American Medical Association (AMA) in collaboration with the ACR and other professional societies and include long-awaited updates to the evaluation and management (E/M) coding and payment for time-intensive, high-value office and outpatient services provided by rheumatologists and other cognitive specialists. If finalized, the rule will increase Medicare reimbursement for services such as examinations, disease diagnosis, risk assessments and care coordination, all frequently provided in rheumatologic care.
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Multipronged, Years-Long Effort
For the last year, ACR staff and volunteers on both the Committee on Rheumatologic Care and Government Affairs Committee provided input to the AMA committees crafting the recommendations, including experts’ perspectives on why reimbursements should be aligned with the value of rheumatologists’ services.
“This was a multipronged effort. We have subject matter experts who work with the AMA to inform this process. It is not an exaggeration to say that they have worked for years to make this happen,” says Colin C. Edgerton, MD, chair of the Committee on Rheumatologic Care and a practicing rheumatologist in Mount Pleasant, S.C. “It is a slow process that requires steady and patient input. It is important for rheumatologists to be AMA members, because it gives us the ability to provide the AMA with rheumatologists to advise their Relative Value Scale Update Committee and Current Procedural Terminology Editorial Panel, the committees that made these recommendations to CMS for the proposed rule.”
The ACR’s advocates “were aided by an ad hoc coalition of other professional medical societies, the Cognitive Care Alliance, which is led by John Goodson, MD, at Harvard Medical School,” adds Timothy J. Laing, MD, Associate Professor of Medicine at the University of Michigan in Ann Arbor. Dr. Laing, a rheumatologist, represented the ACR as an advisor to the AMA on the E/M valuation process.
Reflecting Extensive Training
The proposed code changes are a timely, welcome development for rheumatologists practicing nationwide, says Dr. Edgerton.
“Rheumatologists care for complex patients, spending a great deal of time and effort to consider the diagnosis and treatment options, as well as coordinating care. Furthermore, rheumatologists undergo extended specialty-specific training to prepare for this role. The E/M code is the way that rheumatologists are paid for these efforts, and they have traditionally been undervalued. This has led to several problems, including the shrinking of the rheumatology workforce and reduced access for our patients. The proposed E/M changes will help to reverse this trend,” he says.
A 2018 report on Medicare Payment Policy issue by the Medicare Payment and Advisory Commission, an independent congressional agency that advises Congress on Medicare-related issues, found that healthcare services billed under E/M codes, which include many provided by rheumatologists, were greatly undervalued. This was largely due to a lack of credit for the prolonged, specialized training required to become a rheumatologist, Dr. Edgerton says.
“This needs to be reflected in the E/M codes, and unfortunately, it has not been. Reimbursement has been instead focused on procedure-based activities. Procedures do not adequately reflect the extended training and specialized skills that rheumatologists possess,” he says.
In its announcement, the CMS cited that the updates reflected an administration-wide strategy to provide patients with “better accessibility, quality, affordability, empowerment, and innovation” through these updates. In addition to updating potentially undervalued codes that would reflect the value of cognitive care, the 2020 proposed rule includes implementation of Section 2005 of the Substance Use-Disorder Prevention that Supports Opioid Recovery and Treatment for Patients and Communities Act, which creates a new Medicare Part B benefit for opioid treatment programs. The proposal also expands the list of reimbursable Medicare telehealth services, including services like tobacco and alcohol use counseling, depression screenings, obesity-related behavioral counseling, caregiver assessment and pharmacologic management.
CMS will accept comments to the proposed rule through Sept. 27. The final rule will go into effect on Jan. 1, 2020. The ACR’s leadership will continue to interact with CMS on these issues and provide further feedback in written comments, says ACR President Paula Marchetta, MD, MBA.