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Immunization Implications in CY 2020 MPFS Final Rule

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Two decisions finalized in the CY 2020 Medicare Physician Fee Schedule (MPFS) rule have important implications for vaccine policy and access.

First, CMS decided not to finalize a proposed reduction for injection CPT code 96372 that would have resulted in an automatic reduction in payment for immunization administration. Second, a proposal to include the Adult Immunization Status Measure (AIS) in the Quality Payment Program’s Merit-Based Incentive Payment System (MIPS) and the Medicare Shared Savings Program Accountable Care Organization measure sets was not finalized.

Injection Reduction Tied to Vaccine Administration Not Finalized

The proposed CY 2020 MPFS rule included a payment reduction for CPT code 90673 (Under Therapeutic, Prophylactic, and Diagnostic Injections and Infusions). Because Practice Expense Relative Value Units for code 90673 are linked to immunization administration codes, this proposal would have automatically reduced payment for immunization administration codes. The immunization stakeholder community provided feedback that the linkage between the codes is inappropriate because provider time and practice resources associated with immunizing patients are different than those for other types of injections. Ultimately, CMS did not finalize the proposal, citing the public health importance of appropriately reimbursing providers for vaccinating.

The level of resources required from providers for vaccine inventory management, patient counseling, and claims processing is commonly cited as a barrier to improving low adult vaccination rates. Had the proposal been finalized, the reduced payment for vaccine administration could have further disincentivized providers from vaccinating. CMS’ decision reflects an acknowledgment of the public health significance of vaccination and the importance of removing provider barriers to vaccinating. Importantly, CMS stated that it plans to review the valuations for immunization administration codes, signifying that it may permanently delink administration codes to avoid future reductions.

Adult Immunization Status Measure Not Included in MIPS and MSSP

After proposing to include the AIS composite measure in the MIPS and MSSP programs, CMS ultimately did not finalize the proposal, citing recent changes to the Advisory Committee on Immunization Practices (ACIP) recommendation for pneumococcal vaccination. Pneumococcal vaccination is one of the four vaccination measures included in the composite. In June, the ACIP downgraded its recommendation for the 13-valent pneumococcal conjugate vaccine for adults ages 65 and older from a full recommendation to a shared clinical decision-making recommendation. While CMS reiterated its support for the AIS measure, the agency noted the need to further evaluate the measure and clinical recommendations for inclusion in CMS programs.

CMS had been moving quickly to implement the AIS measure, overriding recommendations from the Measures Application Partnership against inclusion. The MPFS decision marks a reversal from the agency and demonstrates the far-reaching implications of ACIP recommendations. As ACIP continues to update recommendations, including a growing number of shared clinical-decision making recommendations, which are more complex to implement than full recommendations, stakeholders will need to evaluate quality measures in a timely manner to ensure alignment with clinical guidelines.

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