2020 Medicare Part B Fee Schedule

Carl J. Pucci in Finance & Reimbursement

Attached is the 2020 Medicare Part B Fee Schedule, effective 1/1/20 through 12/31/20. To identify the amount for your facility, please locate the appropriate CPT/HCPCS code and match it to the respective facility location column.

As a reminder, the Medicare Part B outpatient therapy cap (KX Modifier) amounts are updated and are $2,080 for occupational therapy, and $2,080 for physical therapy and speech therapy services combined for CY 2020. The targeted medical review process, now-termed Medical Review threshold, amount is $3,000 for PT and SLP services combined and $3,000 for OT services. The Final Rule also reminds providers that the application of therapy caps and therapy caps exception process was repealed effective 1/1/18.

Please refer to the AHCA bulletin below, which provides details of the methodology, as well as related CMS links. 

The 2020 therapy fees for each CPT/HCPCS Code in each geographic area are provided in the attached Excel file: 

  1. The 2020 Medicare Part B Fee Schedule for Outpatient Rehabilitation for each Carrier and Locality (Part B Fees)
  2. The 2020 Medicare Part B MPPR Fee Schedule for "Always Therapy Services (50% MPPR Factor) for each Carrier and Locality (MPPR Fees)
  3. The 2020 Relative Value Units for each Outpatient Rehabilitation Therapy Code (RVUs)
  4. The 2020 Geographic Practice Cost Indices by Medicare Carrier and Locality (GPCI)
  5. The 2020 Counties Included in 2019 Localities (GPCI Counties) (No Changes)


The Part B Fee Schedule amounts are calculated as follows:

        ((A1 x B1) + (A2 x B2) + (A3 x B3)) x Conversion Factor (Part B Fees), and

        ((A1 x B1) + ((A2 x B2) x (1-MPPR Factor) + (A3 x B3)) x Conversion Factor (MPPR Part B Fees), where:

        A1 = Physician Work RVU
        A2 = Non-Facility Practice Expense RVU
        A3 = Malpractice RVU
        B1 = Work GPCI
        B2 = Practice Expense GPCI
        B3 = Malpractice GPCI

        Conversion Factor = $36.0896

        MPPR Factor = 50%

Please note that the fees effective January 1, 2020, are calculated based upon the CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies Final Rule (CMS-1715-F) published in the Federal Register on November 15, 2019. This final rule reflects the requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which repealed the Sustainable Growth Rate formula and provisions related to Medicare payment contained in the Bipartisan Budget Act of 2018 (BBA of 2018) signed into law on February 9, 2018. The CY 2020 conversion factor is $36.0896 which reflects the update adjustment factor of 0.00 percent and the budget neutrality adjustment of 0.14 percent. Further, the BBA of 2018, Section 50201 - Extension of Work Geographic Practice Cost Index (GPCI) Floor, extended a provision raising the Work GPCI to 1.000 for all localities that currently have a Work GPCI of less than 1.000 only through December 31, 2019. This provision has now ended and is not applicable for CY 2020. Additionally, as required by the ACA, the 1.5 work GPCI floor for Alaska and the 1.0 practice expense GPCI floor for frontier states are permanent, and therefore, applicable in CY 2020.

The final rule continues the multiple procedure payment reduction (MPPR) policy for “always therapy” services.  The MPPR policy required, effective April 1, 2013, a 50 percent reduction to be applied to the practice expense component of payment for the second and subsequent “always therapy” service(s) that are furnished to a single patient by a single provider on one date of service (including services furnished in different sessions or in different therapy disciplines). The MPPR worksheet lists those “always therapy” services subject to the MPPR policy and the reduced fee payment amounts.

Further, the Medicare Part B therapy CPT code list for CY 2020 is updated by adding additional codes (90912, 90913, 97129, 97130, 97607, and 97608) and deleting codes (95831, 95832, 95833, 95834, G0515). Please see Transmittal 4421/Change Request 11501 and CMS MLN Matters article MM11501 for more information. Additionally, the Annual Therapy Update and the 2020 Therapy Code List and Dispositions may be found here. Further, the 2020 Part A MAC Update removes CPT Codes 29580 and 29581 from the Major Category I.F Ambulatory Surgery Inclusions and adds them to Major Category V Part B Therapy Inclusions.

Effective for January 1, 2018, Section 50202 of the BBA of 2018 repealed the application of the therapy caps and the therapy caps exceptions process while also retaining and adding limitations to ensure appropriate therapy. A separate provision of Section 50202 of the BBA of 2018 preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier to confirm that services are medically necessary as justified by appropriate documentation in the medical record. Claims for therapy services above these amounts without the KX modifier are denied. These amounts are now known as the KX modifier thresholds. Just as with the incurred expenses for the therapy cap amounts, there is one KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined and a separate amount for occupational therapy (OT) services. For CY 2020, the KX modifier threshold amounts are: (a) $2,080 for PT and SLP services combined, and (b) $2,080 for OT services. The targeted medical review process, now-termed Medical Review threshold, amount is $3,000 for PT and SLP services combined and $3,000 for OT services. Please see Transmittal 4419/Change Request 11532 and Centers for Medicare and Medicaid Services (CMS) MLN Matters article MM11532 for complete information on the KX modifier thresholds.

Finally, supporting documentation and downloads for Regulation #CMS-1715-F may be found here. An overview of the Physician Fee Schedule Payment Policies may be found here and an overview of skilled nursing facility consolidated billing and annual updates may be found here.

Please let me know if you have any questions. 

Resources:

CY 2020 Revisions to Payment Policies under the Physician Fee Schedule and Other Changes to Part B Payment Policies Final Rule (CMS-1715-F) – November 15, 2019 Federal Register

Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2020 – Regulation # CMS-1715-F

Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Final Rule – Transmittal 4468/Change Request 11560

Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Final Rule MLN Matters Article – MM11560

Annual Update to the Per-Beneficiary Threshold Amounts (KX Modifier Thresholds) for CY 2020 – Transmittal 4419/Change Request 11532

Annual Update to the Per-Beneficiary Threshold Amounts (KX Modifier Thresholds) for CY 2020 MLN Matters Article – MM11532

2020 Annual Update to the Therapy Code List – Transmittal 4421/Change Request 11501

2020 Annual Update to the Therapy Code List MLN Matters Article – MM11501

Annual Therapy Update (2020 Therapy Code List and Dispositions)

Medicare Expired Legislative Provisions Extended and Other Bipartisan Budget Act of 2018 Provisions

Physician Fee Schedule Payment Policies

Skilled Nursing Facility Consolidated Billing and Annual Updates

NYSHFA/NYSCAL CONTACT:

Carl J. Pucci
Chief Financial Officer
518-462-4800 x36