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CMS Rules: Direct Supervision Is Gone, Prior Auth Is Here; Documentation Fix Has Limits

CMS has given the green light to prior authorization for five types of procedures in an attempt to control “unnecessary increases” in these procedures as part of its Medicare program integrity strategy, according to the final 2020 Outpatient Prospective Payment System (OPPS) regulation[1] announced Nov. 1. There will be more prior authorization in the future, which will challenge hospitals to improve their pre-service coverage analysis. But they got relief from the direct physician supervision requirement for outpatient hospital therapeutic services. CMS shifted it to the more relaxed general supervision standard in the OPPS regulation and did the same thing for certain services, including remote patient monitoring and physician assistants’ services, in the final Medicare Physician Fee Schedule (MPFS) regulation,[2] also announced Nov. 1.

Absent from the OPPS final regulation is a controversial provision on price transparency.[3] The proposed regulation would have required hospitals to post the charges they’ve negotiated with all payers, as well as prices for a subset of “shoppable” services, which many attorneys consider impractical for hospitals. “What was really gratifying was when you look at the comments, providers and payers were in lockstep that payers have the best information for patients on this,” says Valerie Rinkle, president of Valorize Consulting. Before hospitals get too sanguine, another version of a price transparency regulation is now at the Office of Management and Budget for review, but its content, timing and fate are unknown. Rinkle is hoping it will capitalize on the portals and other tools that payers already have to share the price of services.

There’s a lot of activity on the documentation and evaluation and management (E/M) front in the MPFS regulation. Medicare will continue to pay separately for all office/outpatient visit levels of service, which will have different values to better capture their work relative value units (RVUs). CMS is adopting work RVUs for office/outpatient E/M codes and the new prolonged services add-on code recommended by the RVS Update Committee of the American Medical Association (AMA), and ditching the lowest level CPT code, 99201, for new patients in 2021. At the same time, CMS erased its two-year-old policy for paying non-face-to-face prolonged service codes 99358 and 99359. But a heralded change in the documentation required to support E/M services—allowing physicians the option of using medical decision-making (without exam and history) or time spent with the patient to select the E/M code level—applies only to office/outpatient visits, which limits its usefulness, experts say.

“Whether the changes will achieve CMS’s goals may be debated, but CMS certainly appears to be attempting to reduce burden and align Medicare with requirements of other regulations and other state laws,” says attorney Richelle Marting, with the Forbes Law Group in Overland Park, Kansas.

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