Center for Medicare and Medicaid Services (CMS) Makes Physician Fee Schedule Final Rule

On November 1, the Center for Medicare and Medicaid Services (CMS) released two final rules for Calendar Year 2020, the Medicare Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems. The current Administration is focusing on updating payment policies in the healthcare system which impacts health practitioners, including advanced practice registered nurses (APRNs), as their payments for services furnished are made under the PFS.

Earlier this year, AACN submitted comments to CMS on the PFS and OPPS/ASC proposed rules offering recommendations and improvements upon the proposed policies that impact nursing scope of practice. The following gives detail of which AACN-supported provisions were included in each final rule.

The most significant (and widely supported among AACN's coalition partners) change that CMS adopted into the final rule revises E/M documentation requirements to allow the physicians, PAs and APRNs who furnish and bill under the PFS to review and verify, rather than redocument, medical record notes made by physicians, residents, nurses, students or other members of the medical team. This proposed rule is forward-thinking and reflective of the professional health care setting by including APRN and PA preceptors and broadly interpreting "students" to include all members of the medical team with interprofessional education and training.

AACN also noted that the CMS proposed changes to E/M documentation only included three out of the four APRNs, omitting certified registered nurse anesthetists (CRNAs) who regularly complete comprehensive E/M documentation for patients. In the final rule, CMS stated it is making modifications to explicitly name PA and NP, CNS, CNM an CRNA students as APRN students and amending the regulation to include CRNAs as a category of APRNs.

• Under Payment for Evaluation and Management (E/M) Visits, CMS proposed to enable physician, physician assistant (PA), and the APRN who furnishes and bills for their professional services to review and verify, rather than information included in the medical record by physicians, residents, nurses, students or other members of the medical team. This change to medical record documentation reduces burden and eliminates disparities in clinical training opportunities.
  
  
• AACN recommended that CMS include CRNAs among list of providers in revision to medical record documentation; CMS modifying regulation to include CRNAs.
  
  
• Under Deferring to State Scope of Practice Requirements, revisions proposed for Ambulatory Surgical Centers (ASCs) enable CRNAs to perform the anesthetic risk and evaluation on the patients they are anesthetizing. Performing the comprehensive preanesthetic assessment and evaluation of the risk of anesthesia is within the scope of practice of a CRNA and would help to increase efficiency and eliminate operational waste and delays in care in ASCs across the nation. 
  
  
• Supported changes to Ambulance Physician Certification Statement Requirement to add licensed practical nurses, social workers, and case managers to list of non-physician staff who are authorized to sign a certification statement.

In its August comments to CMS, AACN strongly supported Section X. A. Proposed Changes in the Level of Supervision of Outpatient Therapeutic Services in Hospitals and Critical Access Hospitals (CAHs). This proposal changes the minimum level of supervision from direct supervision to general supervision for all hospital outpatient therapeutic services provided by all hospitals and CAHs. This would increase access to lifesaving therapeutic services, including cardiac and pulmonary rehabilitation, chemotherapy, and radiation therapy, especially for the medically underserved patient populations.

AACN's Recommendations Included in OPPS/ASC Final Rule

• Change in the minimum required level of supervision from direct supervision to general supervision for all hospital outpatient therapeutic services provided by all hospitals and CAHs.

AACN will continue to support CMS initiatives to reduce unnecessary regulatory burdens while increasing access to affordable, quality care by eliminating regulations impeding scope of practice of highly qualified clinicians. AACN continues to emphasize the importance of the following recommendations in future rulemaking: 

• Correct provider attestation to accurately document services billed and remove "incident to" billing
  
  
• Remove the administrative burden requiring physicians to provide face-to-face documentation for Home Health services; 
  
  
• Adopt provider-neutral language in all regulatory interpretations of the law where appropriate; and
  
  
• Amend statutory language to ensure that health-related federal committees and boards reflect diverse representation of the health workforce.