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CMS Proposed Regulations

Centers for Medicare and Medicaid Services (CMS) released proposed regulations earlier this week for the hospital outpatient departments (HOPDs) and ambulatory surgical centers (ASCs​) for. Additionally CMS released annual proposed changes to the Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP)​.  Both proposed rules are for calendar year (CY​) 2020​. Comments are due no later than 5 p.m. EST on September 27, 2019.


Initial review of the HOPD and ASC proposed regulation include:

  • Disclose insurer-negotiated prices and enforcement plan.
    • CMS would require hospital websites to display payer-specific negotiated charges for at least 300 “shoppable services” which is defined as a service that can be scheduled by a health care consumer in advance. CMS would designate 70 of the service charges that must be included in the list, and the hospital would have to choose the remaining 230.
    • Hospitals that did not comply with the regulations could face a monetary penalty of up to $300 per day until they are in compliance or provide a corrective action plan.​
  • Changes to Inpatient and Ambulatory Surgical Center Covered Procedure List
    • Proposed this year include remove total hip arthroplasty (THA) from the inpatient only list while total knee arthroplasty​ (TKA) would be added to the ambulatory surgical center services eligible
  • Phase-in site neutral payments
    • CMS is proposing moving forward with an additional 30% cut. This will bring the national average payment rate will go down from $116 per visit to just $46.​

Initial review of the MPFS and QPP proposed regulation include:

  • For the second year, implement pricing updates based on market specific supply and equipment prices, malpractice expenses, and geographic-based practice costs.
  • CY 2020 PFS conversion factor would be $36.09, a slight increase above the CY 2019 PFS conversion factor of $36.04.
  • Moving back to an evaluation and management (E/M) five-tier visit code system for patients and suggested moving to a four-tier coding system for new patients.
  • Suggested adapting the revised E/M code definitions​ developed by the American Medical Association​ (AMA).
  • Adopting the AMAs RUC-recommended payment rates in which CMS would make payments based on each level of service versus single blended rate for codes level 2-4
  • Consolidating add-on code for “extended visit” to primary care management that requires comprehensive care as well as for non procedural specialty care that is part of treating complex chronic conditions.
  • Requesting comments on changes to global surgery coding
  • Increasing Medicare transitional care management payments for clinicians when a patient leaves the hospital
  • Changes under QPP’s Merit-based Incentive Payment System (MIPS) in the cost and quality performance category
  • Expand Medicare coverage for opioid​​ use disorder treatment services


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