CMS issues final rules for MFPS, HOPPS and ASC
November 1, 2019 – the Centers for Medicare and Medicaid Services (CMS) issued the final rule for the Medicare Physician Fee Schedule (MFPS), Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgery Center (ASC). Highlights are described below.
For MFPS:
RVUs are converted to dollar amounts through the application of the conversion factor (CF). The formula for the calculating the MPFS is as follows:
Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI MP)] x CF
This is the beginning of the transition from the historical fee-for-service MFS payment system to utilization of a budget neutrality adjustment. For CY 2020, the Conversion Factor (CF) is based on a positive 0.14% adjustment, which results in a CF of $36.0896.
Work RVUs are established for new, revised and potentially misvalued codes based on portion of resources used in furnishing the service that reflects physician time and intensity.
Practice Expense RVUs (PE RVUs) are developed by reviewing practice resources involved in providing each service and are comprised of direct and indirect PE. Direct PE consist of the costs of clinical staff, medical supplies, medical equipment. Indirect PE costs are developed primarily on the Physician Practice Expense Information Survey (PPIS).
Malpractice RVUs (MP RVUs) are considered to be resourced based, and required to be reviewed annually to more accurately represent and evaluate mix of practitioners providing services on Medicare claims. There are three factors which are considered to determine MP RVUs for PFS services which consist of specialty-level risk factors; service-level risk factors; and intensity/complexity of service adjustment to the service level risk factor.
For CY 2020, CMS finalized their proposal that the values of the MP RVUs and MP GPCI be coordinated because the MP premium data used to update the MP GPCI is the same to determine the risk levels of the specialties. This change would put the next review for implementation in CY 2023.
CMS is required to develop separate Geographic Practice Cost Indices (GPCIs) to measure cost differences among localities compared to the national average. CMS adjusts reimbursement to align with the cost of those services specific to where they were provided. This is done by applying the GPCI values for a specific area to each of the RVUs (work, practice expense, and malpractice).
Within the CY 2020 proposed rule publication, CMS addressed quite a few of the misvalued and/or proposed value changes to specific series of CPT® codes. Of interest are:
- Iliac Branched Endograft Placement (CPT® Codes 34717 and 34718)
For CY 2018, CPT® created new and revised codes to redefine coding for endovascular repair of the aorta and/or iliac arteries. The iliac branch endograft has become more mainstream, and two new CPT® codes were created to report the work of iliac artery endovascular repair with an iliac branched endograft. For CY 2020, CMS proposed and finalized work RUV of 9.00 for code 34717 and 24.00 for 34718 in addition to RUC-recommended direct PE inputs for all codes in this coding family.
- Intravascular Ultrasound (CPT® Codes 37252 and 37253)
CPT® codes 37252 and 37253 were considered work neutral, which means despite “changes in the coding, the overall amount of work RVUs for a set of services is held constant from one year to the next.” Over time, it was determined the overall work spending for these two codes increased significantly, and thus changed the work neutrality. After further review by the RUC, they recommended a work RVU of 1.80 for code 37252 and a work RVU of 1.44 for 37253. In the proposed rule, CMS disagreed with the RUC-recommended work RVUs. However, in response to the public comment, CMS was persuaded to finalize the RUC-recommended work RVUs.
The CY 2020 MPFS final rule is located in its entirety at the following link:
