CMS Proposals for Physician Payment and Policy Changes in 2019

by | Last updated May 17, 2023 | Published on Jul 24, 2018 | Medical Billing

CMS Proposals Physician Payment
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Our medical billing company keeps track of updates to payment policies, payment rates, and quality provisions for services made under the Medicare Physician Fee Schedule (PFS). On July 12, the Centers for Medicare and Medicaid Services (CMS) released the proposed changes to the Medicare Physician Fee Schedule (PFS) and provisions of the Quality Payment Program (QPP) for 2019.

The Medicare PFS proposals for calendar year (CY) 2019 aim to minimize administrative burden and includes the following:

  • Streamlining evaluation and management (E/M) documentation requirements
    • Improving accuracy for E/M documentation by allowing clinicians to use time as the governing factor to document office and outpatient E/M visits
    • Allowing documentation of medical decision-making or time;
    • Allowing clinicians to focus on documenting new and relevant information rather than re-documenting redundant information
    • Allowing clinicians to review and verify some medical record information entered by staff or the beneficiary instead of re-entering information
  • Improving accuracy for payment rates for E/M levels and simplifying documentation
    • Implementing a single, blended payment rate for office and outpatient E/M levels 2 to 5 visits with a series of add-on codes (new add-on code (GCG0X) to capture the complexity of specialty E/M care and a new add-on code (GPC1X) to capture the complexity of ongoing care provided to an established patient by a primary care physician)
    • Changes to the practice expense formula for these services to account for differences in resource costs among certain types of E/M visits
    • Eliminating the need to justify the necessity of a home visit vs an office visit
    • Removing duplicating notations for teaching physicians that may have been previously documented by residents or other medical staff
  • Modernizing Medicare physician payment to accommodate communication technology-based services: The two new services that CY PFS 2019 identifies for separate payment are:
    • Brief Communication Technology-based Service (such as Virtual Check-in)
    • Remote Evaluation of Recorded Video and/or Images Submitted by the Patient
  • Appropriate Use Criteria/Clinical Decision Support: With regards to the subject of AUC, CMS finalized a January 1, 2020, implementation date in the 2018 final rule. Clinicians should consult with AUC through a qualified clinical decision support mechanism (CDSM) for advanced imaging services starting January 1, 2020.Other proposals include:
    • Reporting the required AUC information on Medicare claims forms using HCPCS G-codes and modifiers.
    • Expanding the requirement to comply with the mandate to Independent Diagnostic Testing Facilities.
    • Revision of significant hardship criteria to include insufficient internet access, electronic health record (EHR) or CDSM vendor issues or extreme and uncontrollable circumstances.
  • Proposals of interest to cardiology: Creating values for new codes describing leadless pacemaker services, subcutaneous quantitative cardiac rhythm monitor services (loop recorder), pulmonary wireless pressure sensor services and chronic care remote physiologic monitoring services, and updating values for external counterpulsation, coronary fractional flow reserve measurement, supervised exercise therapy for peripheral artery disease and cardiac output dilution studies.

Other updates include:

  • Not requiring providers of outpatient therapy services to include functional status information on claims for therapy services.
  • Updating of practice expense relative value units (RVUs) for approximately 1300 supplies and 750 equipment items. These will be implemented over a 4-year period beginning in 2019 to ensure a smooth transition of past practice expense RVUs.
  • Recognizing and paying for communication technology-based and remote evaluation services rendered by rural health clinics (RHCs) and federally qualified health centers (FQHCs).
  • Inclusion of an add-on payment of 6% of the average sales price amount for many Part B drug payments. This will be reduced to 3%, which may reduce excessive spending.
  • Reduction in the number of measures in the Medicare Shared Savings Program quality measure set from 31 to 24, with a focus on outcome-based measures.

2019 QPP Performance Period – Some Proposed Changes

  • Modifying the MIPS Promoting Interoperability (formerly Advancing Care Information) performance category to support greater electronic health record interoperability and patient access while aligning with the proposed new Promoting Interoperability Program requirements for hospitals.
  • Requiring that at least 75 percent of eligible clinicians in an Advanced APM use certified EHR technology.
  • Expanding the definition of Merit-based Incentive Payment System (MIPS) eligible clinicians to include new clinician types such as physical therapists, occupational therapists, clinical social workers, and clinical psychologists.
  • Adding “Number of Covered Professional Services”, a third element to the low-volume threshold determination and providing an opt-in policy that offers eligible clinicians who meet or exceed one or two, but not all, elements of the low-volume threshold the ability to participate in MIPS.
  • Offering the option to use facility-based scoring for facility-based clinicians that does not require data submission.
  • Moving clinicians to a smaller set of Objectives and Measures with scoring based on performance for the Promoting Interoperability performance category.
  • Continual of the small practice bonus, but including it in the Quality performance category score of clinicians in small practices in lieu of as a stand-alone bonus.
  • Raising the MIPS performance threshold for avoiding a penalty to 30 points and the exceptional performance threshold to 80 points.

The full proposal for CY 2019 PFS is available on the CMS website. Clinician feedback on the proposed changes can be submitted to CMS until 5 pm on September 10. The final rule, which will have significant implications for medical billing and coding, will be released in the fall.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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