The AAO-HNS has a long history of working closely with the U.S. Department of Health and Human Services, the Centers for Medicare & Medicaid Services (CMS), and the CMS Innovation Center to maintain our visibility and credibility with national representatives regarding Medicare issues.
We believe that advocacy is the key to defining the future of otolaryngology. Medicare regulatory advocacy is a top priority of the AAO-HNS.
Medicare to Require Prior Authorization for Certain Outpatient Department Services Starting July 1, 2020
In the Calendar Year 2020 Outpatient Prospective Payment System/Ambulatory Surgical Center Final Rule (2020 OPPS Final Rule), the Centers for Medicare and Medicaid Services (CMS) established a prior authorization process and requirements for certain hospital outpatient department (OPD) services in order to help control unnecessary increases in the volume of these services.
Beginning July 1, services requiring prior authorization will include vein ablation, blepharoplasty, botulinum toxin injections, panniculectomy and rhinoplasty. Otolaryngology services impacted include:
- 15820 Removal of excessive skin of lower eyelid
- 15821 Removal of excessive skin of lower eyelid and fat around eye
- 15822 Removal of excessive skin of upper eyelid
- 15823 Removal of excessive skin and fat of upper eyelid
- 20912 Nasal cartilage graft
- 30400 Reshaping of tip of nose
- 30410 Reshaping of bone, cartilage, or tip of nose
- 30420 Reshaping of bony cartilage dividing nasal passages
- 30430 Revision to reshape nose or tip of nose after previous repair
- 30520 Reshaping of nasal cartilage
- 67900 Repair of brow paralysis
- 67901 Repair of upper eyelid muscle to correct drooping or paralysis
- 67902 Repair of upper eyelid muscle to correct drooping or paralysis
- 64612 Injection of chemical for destruction of nerve muscles on one side of face
The full list of HCPCS codes requiring prior authorization is available on the CMS website. This prior authorization requirement is limited to services rendered in the hospital outpatient department only.
Regional Medicare Administrative Contractors (MACs) will administer the prior authorization program which consists of developing the approval criteria, processing the authorization requests, and notifying the requestors and patients of the results. There is no specific form to request prior authorization; however, MACs may make cover sheets or other templates available for voluntary use. Members are encouraged to check their local MAC website for upcoming webcasts and resources on this new process. Prior authorization requests for dates of services beginning July 1, 2020, will be accepted by MACs starting June 17, 2020. The standard review timeframe is ten business days from the date the prior authorization request is received. If this timeframe could seriously jeopardize the life or health of the beneficiary, a provider can request an expedited review of two business days.
The AAO-HNS encourages members performing these services for Medicare patients to review the CMS Prior Authorization Process for Certain Hospital Outpatient Department Services presentation slides, OPD Operational Guide, and Frequently Asked Questions PDF on the CMS Prior Authorization website for additional information and guidance on the program.
AAO-HNS Comments on Medicare Physician Fee Schedule Final Rule
On December 30, the AAO-HNS submitted comments to CMS regarding the CY 2020 Medicare Physician Fee Schedule final rule. In the November 15 federal register notice rule publication, the agency indicated its willingness to solely consider comments on the sections of the rule describing changes to coding and payment for E/M services. Therefore, the Academy’s comment letter reiterated our concerns with the overall E/M coding restructure scheduled to take effect in 2021. Our comments also strongly encourage CMS to reconsider the decision not to apply the increased E/M payments to the corresponding E/M values in the global surgery package.
AAO-HNS Comments on Medicare CY 2020 Hospital Outpatient Proposed Rule
On September 27, the AAO-HNS submitted a comment letter to CMS regarding the CY 2020 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule. The Academy’s comments included support for Medicare’s proposed changes to increase hospital price transparency and designate certain procedures performed by otolaryngologist-head and neck surgeons as permanently office-based; while opposing the increased application of prior authorization policies.
AAO-HNS Comments on Medicare Physician Fee Schedule Proposed Rule
On August 30, the AAO-HNS submitted a comment letter to the Centers for Medicare & Medicaid Services (CMS) on the CY 2020 Medicare Physician Fee Schedule and Quality Payment Program proposed rule. The Academy’s comments focused on the agency’s proposed changes to E/M codes and their value in the global surgery package, valuation of specific codes affecting the specialty, special endoscopy rules, market-based supply and equipment pricing, physician assistant (PA) supervision requirements, as well as comprehensive updates to the Quality Payment Program (QPP).
CMS Releases CY 2020 MPFS/QPP Proposed Rule
On July 29, 2019, the Centers for Medicare and Medicaid Services (CMS) released the CY 2020 Proposed Rule for the Medicare Physician Fee Schedule (MPFS), which also includes proposals related to the Quality Payment Program (QPP). The proposed regulations will be published in the Federal Register on August 14, 2019. Comments are due September 27, 2019. While AAO-HNS physician leaders and staff are still reviewing the over 1,700 page rule, a high-level analysis identified key proposals impacting the specialty.
For 2020, CMS proposes a conversion factor of $36.09, a slight increase from the $36.04 factor in 2019. The rule outlines the agency’s plans to implement many of the changes to E&M codes first introduced in last year’s regulations. CMS is proposing to adopt the CPT-approved updates to E/M visits approved for 2021, which retain 5 levels of coding for established patients, reduce the number of levels to 4 for new patients, and revise the code definitions. CMS is also proposing to implement the RUC-recommended E/M values for CY 2021, which are substantially higher than the current values. However, the rule does not extend these values to the post-operative office visits included in global surgery bundled payments. In Table 111 of the rule, CMS estimates that otolaryngology will receive an overall 5% increase based on the proposed revisions to E/M payment and coding policies.
CMS is proposing the following updates to the Merit-based Incentive Payment System (MIPS) program for the 2020 performance period (2022 payment period). Out of 100 MIPS points available, 40% will be allocated to Quality, 25% to Promoting Interoperability (formerly Advancing Care Information), 20% to Cost, and 15% to Improvement Activities. The proposed performance threshold for 2020 is 45 MIPS Total Points. Eligible Clinicians (ECs) or practices who fail to participate, when required, or meet the performance threshold, may be subject to a negative 9% payment adjustment in 2022.
The Academy is continuing its analysis of the rule and plans to submit comments by the September 27 deadline.
AAO-HNS Comments on CY 2019 Medicare Physician Fee Schedule Final Rule
On December 31, the AAO-HNS submitted a comment letter on the CY 2019 PFS Final Rule thanking CMS for implementing multiple policy changes positively impacting the specialty. Our comments to the agency focused on the following issue areas: 1) application of MPPR to E/M services and E/M code collapse; 2) QCDR measure licensing requirements; 3) allergy vial pricing and practice expense impact; and 4) balloon sinus surgery kits.
AAO-HNS Comments on CY 2019 OPPS & ASC Final Rule
On December 3, the AAO-HNS submitted a comment letter to CMS on the CY 2019 OPPS & ASC final rule. In these comments, the Academy 1) thanked CMS for the removal of CPT Code 31241 from the Inpatient Only (IPO) list, 2) reiterated opposition to the use of prior authorization as a means to minimize overutilization under the Medicare program, 3) expressed concern over the creation of a new C-APC 5163 for Level III ENT Procedures, and 4) thanked the agency for the establishing appropriate payment for HCPCS C9749.
CMS Heeds AAO-HNS Concerns on CY 2019 MPFS
On November 1, 2018, CMS released a final rule implementing changes to the 2019 Medicare Physician Fee Schedule. In response to AAO-HNS advocacy and coordinated efforts across the house of medicine, CMS opted to rescind its proposal to apply an MPPR/Modifier 25 reduction for procedures reported on the same day as an E/M service. In addition, the agency delayed and modified its broad-reaching proposed changes relating to coding and payment for E/M services for new and established patient office visits. Beginning in 2021, which allows more time for stakeholder input, CMS will maintain the billing code for the most complex patients and collapse the current E/M coding system into three tiers. While the AAO-HNS continues its review of the 2,400-page final rule, James C. Denneny III, MD, AAO-HNS EVP/CEO, provided a preliminary analysis.
CMS Releases CY 2019 OPPS and ASC Final Rule
On November 2, 2018, CMS released a final rule implementing changes to the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System for Calendar Year 2019. CMS continued its drive toward site neutrality for outpatient services, specifically clinic visits for outpatient settings. While the proposed rule had recommended the equalization in payment occur in CY 2019, the OPPS final rule describes phasing in this change over two years.
AAO-HNS Comments on Medicare CY 2019 Hospital Outpatient Proposed Rule
On September 24, the AAO-HNS submitted a comment letter to CMS regarding the CY 2019 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule. The Academy’s comments included support for Medicare’s proposed changes to reduce site of service disparities, as well as removal of CPT 31241 (Nasal/sinus endoscopy, surgical; with ligation of sphenopalatine artery) from the Inpatient Only List. View the letter here.
AAO-HNS Submits Comments on Medicare Physician Fee Schedule Proposed Rule
On September 10, the AAO-HNS submitted a comment letter to the Centers for Medicare & Medicaid Services (CMS) addressing several components of the CY 2019 Medicare Physician Fee Schedule (MPFS) proposed rule. The Academy’s comments focused on Medicare’s proposed changes to documentation requirements, coding and payment for Evaluation and Management (E/M) services, application of the MPPR to E/M services, and the pricing and composition of balloon sinus surgery kits. View the letter here.
CMS Releases CY 2019 MPFS/QPP Proposed Rule
On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the CY 2019 Proposed Rule for the Medicare Physician Fee Schedule (MPFS). While in previous years regulations for the Quality Payment Program (QPP) were released independently, the 2019 MPFS proposed rule includes proposals related to Medicare physician payment, as well as the QPP. You may view the proposed rule here.
CMS proposes an updated CY 2019 conversation factor of $36.0463, which reflects the 0.25 percent update specified by the Medicare Access and CHIP Reathorization Act (MACRA) and a budget neutrality adjustment of -0.12 percent. Overall, this is a slight increase from the current conversion factor of $35.9996.
While the AAO-HNS physician leaders and staff are still reviewing the nearly 1,500 pages of the proposed rule, a few items specifically impacting the specialty should be noted. First, the rule proposes replaces existing E/M coding documentation guidelines for office and outpatient visits and collapsing payments from five levels to either two or three levels. Further, the rule proposes a 50 percent multiple procedure reduction when reporting an E/M service and a procedure on the same date.
The Merit-based Incentive Payment System (MIPS) portion of the proposed rule retains the low-volume threshold, but adds a third criteria of providing <200 covered professional services to Part B patients, as well as an opt-in mechanism. Payment adjustments could be as high as +7 percent or as low as -7 percent, and eligible clinicians must use the 2015 Edition certified EHR technology (CEHRT) in Year 3. The rule also further modifies the weighting for the four performance categories:
- Quality: 45%
- Cost: 15%
- Promoting Interoperability (formerly Advancing Care Information): 25%
- Improvement Activities: 15%
To review a more in-depth review of requirements for Year 3 of the QPP (CY 2019), visit https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2019-QPP-proposed-rule-fact-sheet.pdf.
The Academy plans to submit comprehensive comments to CMS by the September 10 deadline.
CPT 30520 Reshaping of nasal cartilage