Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2020 (CMS-1715-P)
2019-09-17 2019-09-17 2019-09-17 2019-09-17 2019-09-17 2019-09-17 2019-09-17 2019-09-17 2019-09-17 2019-09-17
CMS-2019-0111-6442 CMS-2019-0111-6412 CMS-2019-0111-6590 CMS-2019-0111-6713 CMS-2019-0111-6706 CMS-2019-0111-6705 CMS-2019-0111-6759 CMS-2019-0111-6644 CMS-2019-0111-6631 CMS-2019-0111-6629
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https://api.regulations.gov/v4/comments/CMS-2019-0111-6442 https://api.regulations.gov/v4/comments/CMS-2019-0111-6412 https://api.regulations.gov/v4/comments/CMS-2019-0111-6590 https://api.regulations.gov/v4/comments/CMS-2019-0111-6713 https://api.regulations.gov/v4/comments/CMS-2019-0111-6706 https://api.regulations.gov/v4/comments/CMS-2019-0111-6705 https://api.regulations.gov/v4/comments/CMS-2019-0111-6759 https://api.regulations.gov/v4/comments/CMS-2019-0111-6644 https://api.regulations.gov/v4/comments/CMS-2019-0111-6631 https://api.regulations.gov/v4/comments/CMS-2019-0111-6629
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Sept 12, 2019Centers for Medicare amp; Medicaid ServicesDepartment of Health and Human ServicesAttention: CMS1715PP.O. Box 8016Baltimore, MD 212448016RE: Medicare Program; CY 2020 Revisions to Payment Policies under the Physician Fee Schedule andOther Changes to Part B Payment Policies; Medicare Shared Savings Program Requirements; MedicaidPromoting Interoperability Program Requirements for Eligible Professionals; Establishment of anAmbulance Data Collection System; Updates to the Quality Payment Program; Medicare Enrollment ofOpioid Treatment Programs and Enhancements to Provider Enrollment Regulations Concerning ImproperPrescribing and Patient Harm; and Amendments to Physician Self-Referral Law Advisory OpinionRegulations [CMS-1715-P]Dear Administrator Verma:I am writing in response to the request for comments on the Centers for Medicare and Medicaid Services(CMS) Calendar Year (CY) 2020 Revisions to Payment Policies under the Physician Fee Schedule (PFS)and Other Revisions to Medicare Part B proposed rule.I am a physical therapist assistant and am concerned about this potential regulation change.  Physical therapy and occupational therapy services are critically important for improving patient function in order to return home or maintain their highest level of independence and quality of life.I appreciate the opportunity to provide feedback to CMS on the proposed rule. Specifically, I am writingin response to CMS proposed application of the CQ/CO modifier when outpatient physical therapy andoccupational therapy services are furnished in whole or in part by a physical therapist assistant (PTA) oroccupational therapy assistant (OTA).I understand that Section 53107 of the Bipartisan Budget Act of 2018 (BBA), enacted on February 9,2018, included the assistant adjustment as a pay-for provision related to the repeal of the Medicare Part Bpayment cap for therapy services. However, if finalized as proposed, this policy will negatively affectMedicare beneficiary access and add administrative burden. Further, if the application of the modifiers isfinalized as proposed, the access to and safety of vital outpatient physical and occupational therapyservices for the most vulnerable physically impaired beneficiaries will be compromised.I ask the Secretary to not finalize these policies as proposed. Instead, I am requesting that CMS, infinalizing the therapy assistant adjustment provisions of Section 1834 of the BBA, implement thefollowing policy:1. When a therapist and assistant are jointly furnishing services to a patient at the same time as ateam, and the therapist is fully engaged in the service during that time, the service during thattime period should be identified as a therapists services and be allocated to the therapist.2. That CMS define in whole or in part to mean skilled therapy service furnished by a PTA or anOTA that is furnished under the supervision of a therapist, but independent of any time thetherapist is furnishing the service.3. That only those units of services provided in whole or in part by the assistant should be subjectto the 10% de minimis standard, the CQ/CO modifier, and subsequently the 15% paymentadjustment, not all units of the entire therapy service.4. That no new burdensome documentation requirements be added. At a maximum, sub regulatoryguidance could revised to include a statement such as The provider should have a mechanism inplace to provide evidence whether a specific service was furnished independently by a therapistor an assistant, or was furnished in part by an assistant in sufficient detail to permit thedetermination of whether the de minimis threshold was met.Thank you for the opportunity to comment on the CY 2020 Medicare Physician Fee Schedule andproposed rule.Sincerely,Alvin FallPTA I am writing in strong support of CMS efforts to eliminate unnecessary administrative barriers by simplifying current documentation requirements for evaluation and management (E/M) services. Currently, CMS only allows E/M documentation provided by medical students to be verified, rather than re-performed, by teaching physicians for billing purposes. This places a significant burden on physician, PA, and NP preceptors of PA and NP students and restricts the ability of preceptors to train the future health workforce. I therefore applaud CMS recognition of this issue and its proposed changes, which would allow all preceptors to verify the documentation provided by medical, PA, and NP students. This will allow preceptors more time to train students and provide patient care.The proposed rule clearly intends to allow NPs, PAs, and other preceptors to verify, rather than re-perform, documentation provided by students in the medical record. Therefore, I urge CMS to specifically name PAs and NPs as clinicians eligible to verify documentation, rather than including them as other members of the medical team, which may lead to unnecessary confusion. Rather than stating that the documentation of students can be verified, the term medical, PA, and NP students should be utilized. By explicitly naming the types of clinicians and students for which documentation can be reviewed and verified, misinterpretation on the part of health systems, providers, and educators can be eliminated - thus improving both clinical training opportunities and, ultimately, patient care.I further encourage CMS to reexamine the current physical presence requirement that results in significant burden for preceptors when students are participating in patient care. While physical presence in the clinic is critical for safe patient care, presence in the examination room during documentation is onerous and unnecessary. I am writing in strong support of CMS efforts to eliminate unnecessary administrative barriers by simplifying current documentation requirements for evaluation and management (E/M) services. Currently, CMS only allows E/M documentation provided by medical students to be verified, rather than re-performed, by teaching physicians for billing purposes. This places a significant burden on physician, PA, and NP preceptors of PA and NP students and restricts the ability of preceptors to train the future health workforce. I therefore applaud CMS recognition of this issue and its proposed changes, which would allow all preceptors to verify the documentation provided by medical, PA, and NP students. This will allow preceptors more time to train students and provide patient care.The proposed rule clearly intends to allow NPs, PAs, and other preceptors to verify, rather than re-perform, documentation provided by students in the medical record. Therefore, I urge CMS to specifically name PAs and NPs as clinicians eligible to verify documentation, rather than including them as other members of the medical team, which may lead to unnecessary confusion. Rather than stating that the documentation of students can be verified, the term medical, PA, and NP students should be utilized. By explicitly naming the types of clinicians and students for which documentation can be reviewed and verified, misinterpretation on the part of health systems, providers, and educators can be eliminated - thus improving both clinical training opportunities and, ultimately, patient care.I further encourage CMS to reexamine the current physical presence requirement that results in significant burden for preceptors when students are participating in patient care. While physical presence in the clinic is critical for safe patient care, presence in the examination room during documentation is onerous and unnecessary. Thank you for recognizing and addressing the disparity between student documentation requirements for teaching physicians and their students and those for advanced practice nurses (APRNs) and physician assistants (PAs) preceptors and their students. Currently, CMS allows teaching physicians to review and verify any student documentation of the components of E/M services in the medical record, rather than re-document the work. However, this burden reduction policy was not applied to APRN/PA preceptors and their students. Excluding APRN/PA preceptors and their students from this policy had the unintended effect of heightening the challenge of securing preceptors for APRN/PA students when teaching clinicians are in short supply. The revision contained in the Medicare Physician Fee Schedule proposed rule will authorize all APRNs /PAs and physicians to review and verify rather than re-document work for all E/M services by all members of the medical care team (including APRN/PA students). This will remove the disparity and lead to parity among providers and burden reduction for all clinicians. Therefore, we support the inclusion of APRN/PAs in the proposed rule.For additional information, please contact the AANP Government Affairs Office at 703/740-2529 or governmentaffairs@aanp.org. As a physical therapist and employer of 5 Physical Therapists assistants, I urge the payment policy be reviewed and deemed not beneficial for patient care.  The use of physical therapists assistants in the healthcare world is vital for efficiency and quality.  The proposed decrease in reimbursement will negatively impact employment and likely lead to additional shortages of rehab professionals through the country.  I fully understand the need for cost containment however strongly disagree with this methodology. I urge your committee or group to reconsider the payment reduction.Sincerely, Joe Walters PTOwner, Physical Therapy OnePortage, MI 49024    I am writing in strong support of CMS efforts to eliminate unnecessary administrative barriers by simplifying current documentation requirements for evaluation and management (E/M) services. Currently, CMS only allows E/M documentation provided by medical students to be verified, rather than re-performed, by teaching physicians for billing purposes. This places a significant burden on physician, PA, and NP preceptors of PA and NP students and restricts the ability of preceptors to train the future health workforce. I therefore applaud CMS recognition of this issue and its proposed changes, which would allow all preceptors to verify the documentation provided by medical, PA, and NP students. This will allow preceptors more time to train students and provide patient care.The proposed rule clearly intends to allow NPs, PAs, and other preceptors to verify, rather than re-perform, documentation provided by students in the medical record. Therefore, I urge CMS to specifically name PAs and NPs as clinicians eligible to verify documentation, rather than including them as other members of the medical team, which may lead to unnecessary confusion. Rather than stating that the documentation of students can be verified, the term medical, PA, and NP students should be utilized. By explicitly naming the types of clinicians and students for which documentation can be reviewed and verified, misinterpretation on the part of health systems, providers, and educators can be eliminated - thus improving both clinical training opportunities and, ultimately, patient care.I further encourage CMS to reexamine the current physical presence requirement that results in significant burden for preceptors when students are participating in patient care. While physical presence in the clinic is critical for safe patient care, presence in the examination room during documentation is onerous and unnecessary. CMS, I strongly disagree with the CY 2020 Medicare Physician Fee Schedule Proposed Rule update to certain CPT codes for cardiac PET Imaging (CPT codes 78491, 78492, 78x31, 78x32).  I disagree with this policy as it is based off of incorrect data and observation. It appears that inaccurate overhead data, a lack of thorough survey inputs and non-real world assumptions have caused Medicare and the RUC to recommend changes to the work inputs associated with Direct Expense and Practice Expense values, that combined with an inaccurate utilization rate resulted in a proposed reimbursement decline that is significant enough to make it impossible for facilities to continue to offer cardiac PET services after January 1, 2020.The RUC and Medicare relied on market survey data to provide inputs for calculating the technical component (TC) reimbursement. These flawed surveys provided incorrect data or incomplete data regarding equipment direct expense, utilization rate, and practice expense inputs.  In addition, the surveys failed to assess the true cost of starting, operating, and maintaining a cardiac PET lab, omitting input allowances for numerous high cost requirements.  Therefore, based on this flawed survey data, both the RUC and Medicare recommended a reimbursement value well below what is necessary for the technical operation of a cardiac PET laboratory.  I request that CMS NOT commence with the proposed reimbursement in 2020 and instead allow reimbursement to continue at current levels. Dear Administrator Verma,RE: CMS-2019-0111-0092I am writing today to comment on the CY 2020 Revisions to Payment Policies under the Physician Fee Schedule (CMS-1715-P). Specifically, I strongly support the proposal to allow Certified Registered Nurse Anesthetists (CRNAs) to provide the pre-anesthetic assessment in Ambulatory Surgical Centers (ASCs) as part of the Conditions for Coverage (CfC). This change would relieve ASC regulatory burden associated with operating the Medicare program, reduce healthcare costs, and ensure patient safety. CRNAs are highly educated anesthesia experts who are fully qualified to provide the pre-anesthesia assessment. In fact, performing the pre-anesthetic assessment and evaluation of the risk of anesthesia is within the scope of practice of a CRNA. This proposal would align the anesthetic risk and pre-surgery evaluation standard with the post-anesthetic evaluation standard and would promote continuity of care for the patient by allowing the patients anesthesia professional to have familiarity with the patients health characteristics and medical history.  In many facilities, CRNAs may be the only anesthesia providers, and, therefore, the only healthcare professionals possessing the expertise and training to perform the pre-anesthetic evaluation. Modification of this requirement would promote efficiency and flexibility in ASCs and will reduce administrative burden.This is the right proposal for patients and for the healthcare system, and I urge you to ensure that it is included in the final rule.  Thank you for taking the time to review these comments.Sincerely,Pamela Thurman726 Marina Village DrGrand Rivers, KY 42045-9010   Dear Administrator Verma,RE: CMS-2019-0111-0092I am writing today to comment on the CY 2020 Revisions to Payment Policies under the Physician Fee Schedule (CMS-1715-P). Specifically, I strongly support the proposal to allow Certified Registered Nurse Anesthetists (CRNAs) to provide the pre-anesthetic assessment in Ambulatory Surgical Centers (ASCs) as part of the Conditions for Coverage (CfC). This change would relieve ASC regulatory burden associated with operating the Medicare program, reduce healthcare costs, and ensure patient safety. CRNAs are highly educated anesthesia experts who are fully qualified to provide the pre-anesthesia assessment. In fact, performing the pre-anesthetic assessment and evaluation of the risk of anesthesia is within the scope of practice of a CRNA. This proposal would align the anesthetic risk and pre-surgery evaluation standard with the post-anesthetic evaluation standard and would promote continuity of care for the patient by allowing the patients anesthesia professional to have familiarity with the patients health characteristics and medical history.  In many facilities, CRNAs may be the only anesthesia providers, and, therefore, the only healthcare professionals possessing the expertise and training to perform the pre-anesthetic evaluation. Modification of this requirement would promote efficiency and flexibility in ASCs and will reduce administrative burden.This is the right proposal for patients and for the healthcare system, and I urge you to ensure that it is included in the final rule.Sincerely,Ursula Waller128 Marshall RdBuckhead, GA 30625-2906   Dear Administrator Verma,RE: CMS-2019-0111-0092I am writing today to comment on the CY 2020 Revisions to Payment Policies under the Physician Fee Schedule (CMS-1715-P). Specifically, I strongly support the proposal to allow Certified Registered Nurse Anesthetists (CRNAs) to provide the pre-anesthetic assessment in Ambulatory Surgical Centers (ASCs) as part of the Conditions for Coverage (CfC). This change would relieve ASC regulatory burden associated with operating the Medicare program, reduce healthcare costs, and ensure patient safety. CRNAs are highly educated anesthesia experts who are fully qualified to provide the pre-anesthesia assessment. In fact, performing the pre-anesthetic assessment and evaluation of the risk of anesthesia is within the scope of practice of a CRNA. This proposal would align the anesthetic risk and pre-surgery evaluation standard with the post-anesthetic evaluation standard and would promote continuity of care for the patient by allowing the patients anesthesia professional to have familiarity with the patients health characteristics and medical history.  In many facilities, CRNAs may be the only anesthesia providers, and, therefore, the only healthcare professionals possessing the expertise and training to perform the pre-anesthetic evaluation. Modification of this requirement would promote efficiency and flexibility in ASCs and will reduce administrative burden.This is the right proposal for patients and for the healthcare system, and I urge you to ensure that it is included in the final rule.Sincerely,Jaclyn Taylor108 S Elmhurst AveMount Prospect, IL 60056-3125  