Resource to Navigate Changes in Medicare Payments


CMS Finalizes Physician Payment Rule Estimated to Increase Endocrine Payments by 16%

On November 1, 2019 the Centers for Medicare and Medicaid Services (CMS) finalized its Medicare physician payment rule. We are pleased to inform you that the final rule updates evaluation and management (E/M) codes and provides coverage for prolonged visits and principal care management services, reversing a 2018 measure that would have significantly cut payments to endocrinology. These changes stem from over a year of advocacy from the Society and its members and will result in an estimated 16% increase for the services endocrinologists provide. Starting in 2021, the final rule makes the following changes to E/M services:

  • Retains 5 code levels for established patients
  • Eliminates CPT code 99201, the lowest level new patient E/M code
  • Revises the times and medical decision-making process for all the codes
  • Requires a history and exam only as appropriate

For 2020, CMS is finalizing a proposal to increase payment for transitional care management services, adding a specific code for additional time spent beyond the initial 20 minutes allowed for the current chronic care management codes, and creating a new code for principal care management services for patients with only a single serious and high-risk chronic condition.

Despite advocacy efforts from the Society and the broader thyroid community, CMS is maintaining the current values for the thyroid fine-needle aspiration codes (10005 and 10021) rather than placing them on a final list of potentially misvalued codes. This will result in a reduction in payment for these services. We will continue to advocate for increased payments for these services and will inform our members of any changes that may result from these efforts.

We thank all Endocrine Society members who worked with us to successfully advocate for E/M payment and who completed the RUC survey, which helped influence CMS's decisions. Our advocacy works and made a difference.

New summaries of the payment policies can be found below:

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) ended the Sustainable Growth Rate formula for Medicare reimbursement. For eligible clinicians, the Quality Payment Program (QPP) replaces previous Medicare Part B payment programs with the Merit-based Incentive Payment Program (MIPS) and Advanced Alternative Payment Models (Advanced APMs). Explore information and resources to learn how this affects your practice. Questions? Email us at [email protected].

SPOTLIGHT: Quality Payment Program Resource Library


What is MACRA?

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 is legislation that established a new payment system for doctors who treat Medicare patients, changing the way Medicare doctors are reimbursed. Under MACRA, the Sustainable Growth Rate (SGR) Formula was repealed, and providers are instead paid based on the quality and effectiveness of the care they provide.

What is the Quality Payment Program?

Quality Payment Program (QPP) is the name of the Medicare payment program set in place by MACRA. QPP allows Medicare providers to choose one of two payment tracks: Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (Advanced APMs).

How does this affect me or my practice?

You can find out whether you are part of the QPP by entering your provider number into the tool on this page: qpp.cms.gov/learn/eligibility. Providers are part of the QPP if:

  • You participate in an Advanced APM or
  • You bill Medicare more than $90,000 in Part B allowed charges per year OR provide care for more than 200 Medicare patients per year

There is additional technical support available for practices in Small, Rural and Health Professional Shortage Areas (HPSAs). If you meet the eligibility requirements above, you must begin participation in the QPP on January 1 of the reporting year. Performance data for Year 1 must be submitted by March 31, 2018 in order to avoid a payment penalty.


Understanding the Measurement Criteria and Reporting Requirements

The Merit-based Incentive Payment System (MIPS) uses performance-based measures to determine Medicare payment adjustments. Medicare will use the four categories below to determine whether eligible physicians participating in MIPS will receive a positive, negative, or neutral payment adjustment to their Medicare payments. Click on the icons below to select and download the measurement CSV files for Quality, Advancing Care Information, and Improvement Activities. Fora full list of measures for each category, please see the links below. 

QualityQuality (45%)
Replaces PQRS. Report at least six measures for the full calendar year.

Advancing Care InformationAdvancing Care Information (25%)—Replaces Medicare EHR Incentive Program (Meaningful Use). Fulfill the required measures for a minimum of 90 days.

Improvement ActivitiesImprovement Activities (15%)mdash;110+ activities focused on care coordination, beneficiary engagement, and patient safety. Attest that you completed up to 4 Improvement Activities for a minimum of 90 days.

CostCost (15%)mdash;Replaces Value-Based Modifier. No data submission required. Calculated from adjudicated claims.

Advanced APMs

Participating in Advanced APMs

You may be exempt from MIPS if you participate in an alternative payment model. Alternative Payment Models (APMs) are payment approaches that give incentives for high-quality and cost-efficient care. Advanced APMs are a type of APM that allow practices to take on some risk related to patient outcomes. To find Advanced APMs accepting enrollment, please visit innovation.cms.gov.

In 2019, clinicians who participate in one of the Advanced APMs listed below will be exempt from the MIPS reporting requirements and will receive a 5% payment bonus from 2019 – 2024. If you leave an Advanced APM during 2018, make sure you have met the Advanced APM threshold or submit MIPS data to avoid a penalty.

Qualifying Advanced APMs


Endocrine Society Resources

Centers for Medicare & Medicaid Services

Quality Payment Program—A regularly updated resource to help eligible providers understand QPP components. Includes:

Transforming Clinical Practice Initiative—The initiative is one part of a strategy advanced by the Affordable Care Act to strengthen the quality of patient care and spend health care dollars more wisely.

Support for Small Practices—List of QPP technical assistance by region for practices with 15 or fewer clinicians.

American Medical Association

MIPS Action Plan—A resource for physicians not yet participating in the new Medicare payment program is designed to help practices prepare for, and operate under, the regulation.

Preparing Your Practice for Value-based Care—This module will help the user transition to a value-based care model.

Inside Medicare's New Payment System (Podcast Series)—Podcasts presented by ReachMD that cover various topics related to QPP, such as MACRA for small practices and how to use an EHR to participate in MACRA

American College of Physicians

MACRA and the Quality Payment Program resource center


MACRA—Medicare Access and CHIP Reauthorization Act of 2015 is landmark legislation that changes how Medicare pays physicians.

QPP—Quality Payment Program is the new Medicare Part B payment program focused on care quality.

MIPS—Merit-based Incentive Payment System is the payment system for eligible clinicians who are not participating in an Advanced APM. The payments in MIPS are based on four categories: Quality, Improvement Activities, Advancing Care Information, and Cost.

APM—An Advanced Payment Model is a payment approach that gives added incentive payments to provide high-quality and cost-efficient care.

Advanced APM—Advanced Alternative Payment Models are a subset of APMs that let practices earn more for taking on some risk related to their patients' outcomes.

CMS—Centers for Medicare & Medicaid Services is a US federal agency under the Department of Health and Human Services which administers Medicare, Medicaid, and the State Children's Health Insurance Program.

HHS—United States Department of Health and Human Services


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