September 26, 2019

ACR Submits Comments on 2020 MPFS Proposed Rule

The American College of Radiology® (ACR) commented on numerous issues and made specific recommendations in a September 23, 2019, letter to the Centers for Medicare and Medicaid Services (CMS) concerning the 2020 Medicare Physician Fee Schedule (MPFS) proposed rule and proposed changes to the Quality Payment Program (QPP).

The ACR commented on changes to the Evaluation and Management (E/M) services. For calendar year (CY) 2021, CMS proposes to build on changes it finalized last year to reduce administrative burden, improve payment rates and reflect current clinical practice. CMS proposes to adopt the new coding, prefatory language and interpretive guidance framework issued by the American Medical Association (AMA)/Current Procedural Terminology® (CPT®) to further reduce the burden of documentation. In addition, CMS proposes to adopt the AMA/Specialty Society Relative Value Scale (RVS) Update Committee (RUC)-recommended work RVUs for the E/M codes and the new prolonged services add-on code.

Based on analysis conducted by The Moran Company, office-based E/M services constitute roughly 25 percent of all MPFS spending, and an increase in valuation of these services, without any offset to the conversion factor, would result in increased reimbursement to E/M services of $5 billion dollars in a single year. The ACR commented that we have significant concerns because within the budget neutral mandates of the MPFS, even a small increase in E/M payments has large effects on specialties, like radiology, that do not bill E/M codes frequently. Adoption of the RUC-recommended work RVUs for E/M codes and the new prolonged services add-on code will have a devastating impact these specialties.

If CMS was to implement the changes to the E/M services in CY 2020, the estimated impact according to the proposed rule is 8 percent reduction to radiology, 6 percent reduction to interventional radiology, 5 percent reduction for nuclear medicine, and 4 percent reduction for radiation oncology and radiation therapy centers. The impact to radiology may be greater depending on what CMS decides to do with payment for office visit E/M codes captured in the 10- and 90-day global codes and the complexity add-on code.

The ACR requested that CMS make available the impacts at the CPT code level as soon as possible, and that before the agency makes any final decisions, further discussion of impacts and budget neutrality implications must take place in the future rules issued for review and comments. Changes to the E/M services are effective January 1, 2021, so a lot can change between now and then.

In the event that CMS decides to finalize updates to the E/M codes in CY 2021, the ACR proposed the following remedies:

1) For CMS to maintain the same relativity among E/M services and all other services as exists in today’s Physician Fee Schedule (PFS) as the intent of this effort was not this massive redistribution of MPFS payments. This includes working with the ACR on ways to maintain relativity and payment rates for radiology services.
2) CMS’ support when the medical community work with Congress to implement positive updates to the conversion factor (CF) to help offset these losses.
3) If these reductions are implemented, a dampening policy should be established to phase in the reductions over four years. In addition, there should be a ceiling and a floor threshold in terms of percent increase/decrease in payment in a given year.

The ACR commented on many items in the QPP portion of the 2020 MPFS proposed rule and also addressed the following topics:

• Physician Supervision for Physician Assistants
• Potentially Misvalued Services
• Market-Based Supply and Equipment Pricing Update Valuation of Specific Codes

Quality Payment Program
• Merit-based Incentive Payment System (MIPS) Value-based Pathways
• MIPS Value Pathway (MVP) Population Health Quality Measure Set
• Patient Reported Measures
• MVP as Permanent MIPS Participation Solution
• MIPS: Quality Performance Category
• MIPS: Improvement Activity (IA) Performance Category
• MIPS: Promoting Interoperability Performance Category
• MIPS: Cost Performance Category
• MIPS: Qualified Clinical Data Registry (QCDR)
• MIPS: Targeted Review
• Medicare Shared Savings Program (MSSP)
• Physician Compare

For questions on the 2020 MPFS proposed rule or the ACR comments on the rule, please contact Angela Kim at