2019 Physician Fee Schedule High Level Summary
Payment and Other Policy Changes
• Conversion Factor: The CY 2019 PFS conversion factor is 36.0391, a +0.11 percent increase over CY 2018.
• Valuation of Specific Codes: CMS finalized work RVUs and practice expense refinements for new, revised and potentially misvalued codes for CY 2019. Some of these codes will be of interest to you. The list begins on page 21 of our summary.
• Direct PE Inputs: Market-based Supply and Equipment Pricing Update. CMS hired a contractor to gather and analyze new data for updating its supply and equipment pricing to refine direct PE inputs. In addition to make a number of proposals related to how CMS plans to incorporate this new data, CMS requested specific input on two allergy/immunology codes because of the disproportionate impact it has on the codes (even if CMS was to phase in the data). In particular CMS requested input on the direct PE pricing for:
o CPT 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses))
o CPT 95004 (Percutaneous tests (scratch, puncture, prick) with allergenic extracts, immediate type reaction, including test interpretation and report by a physician, specify number of tests)
CMS finalized the use of the data (and the 4 year phase in) but did not directly address any comments received about CPT 95165 or CPT 95004.
• E/M Visits. CMS proposed a series of changes to E/M claims and documentation. CMS finalized some of its documentation proposals, delayed some of the payment proposals, and abandoned several of their related proposals altogether. CMS estimates that the impact of the cumulative finalized polices (once completely implemented, which is not slated until 2021) on allergy/immunology will, on the whole, be neutral (which is an improvement from the expected cut generated by the original proposals). Notable in the final rule:
o CMS modified its proposed policy to collapse office/outpatient E/M visit Levels 2 – 5 into a single payment level to doing so just for Levels 2 – 4 in CY 2021; physicians would still submit claims for visit levels 2-4, but because 2-4 receive the same payment level, only documentation needed to obtain a Level 2 is required (when documenting by current guidelines of MDM only.
o As proposed, CMS finalized that physicians will be able to choose whether to document via the existing 1995 or 1997 guidelines OR just medical decision making OR just by time (although this was also delayed to CY 2021).
o CMS finalized its proposal that for new and established patients, practitioners would no longer be required to re-enter information in the medical record regarding the chief complaint and history already entered by ancillary staff or the beneficiary (effective January 1, 2019).
o CMS did not finalize its proposal to apply the Multiple Procedure Payment Reduction (MPPR) policy to E/M visits billed on the same day as a global procedure.
o CMS finalized two level 2-4 E/M add-on codes: one for primary care and one for “non-procedural specialized care” (defined by a list of clinical areas which includes allergy/immunology).
o CMS finalized a modified version of its proposed new prolonged services E/M code (now referred to as an Extended Visit Service add-on code)
• Changes to Teaching Physician Documentation for E/M Services. Under current billing rules, for procedural services, the participation of the teaching physician can be demonstrated by the notes in the medical records made by a physician, resident, or nurse. However, for E/M visits, the teaching physician is required to “personally document their participation in the medical record.” CMS finalized its proposal to eliminate the requirement teaching physician to personally be the one to document his/her presence and participation. CMS finalized that that the medical record must just document that the teaching physician was present at the time the service is furnished and that the note can be included by the physician, nurse, or resident.
• Telehealth Services (and “Communication-Based Technology Services”). In addition to the typical discussion about potentially adding codes to the list of telehealth services, in the proposed rule, CMS made a major statutory interpretation change by essentially stating that the statutory restrictions on telehealth services should only be applied “to a discrete set of physicians’ services that ordinarily involve, and are defined, coded, and paid for as if they were furnished during an in-person encounter between a patient and a health care professional.” Thus, CMS proposed a series of “communication technology-based services” for separate payment (e.g. virtual check-ins and interprofessional consultations) since they were never intended to be face-to-face patient interactions anyway and therefore are not governed by the statutory restrictions on what Medicare can pay for as telehealth. CMS finalized payment for these services.
• Price Transparency. In the proposed rule, CMS reiterated the language it has placed in several recent rules regarding price transparency and how it hopes to better relay cost information to beneficiaries in a way that patients find meaningful. CMS continues to be concerned about surprise billing for out-of-network services. In the final rule, CMS simply stated that it received 94 comments on the topic and thanks commenters for their input.
• Part B Drugs: CMS finalized that effective January 1, 2019, WAC based payments for Part B drugs utilize a 3 percent add-on in place of the 6 percent add-on, consistent with MedPAC’s recommendation.
Quality Payment Program (QPP)
A detailed list of the QPP changes finalized for 2019 is available through this CMS fact sheet. Additional specific topics that might be of particular interest to your organization are highlighted below.
o CMS finalized 2019 performance category weights as proposed:
o Quality: 45%
o Cost: 15%
o Promoting Interoperability: 25%
o Improvement Activities: 15%
o CMS finalized a performance threshold of 30 points, and an exceptional performance threshold of 75 points for the 2019 period.
o CMS finalized a small practice bonus of 6 bonus points added to the quality performance category numerator.
o Appendix 1, Table Group A: New MIPS quality measures finalized for inclusion in MIPS for the 2019 performance period and future years
o Appendix 1, Table Group B: Finalized new and modified quality measure specialty sets.
o Appendix 1, Table Group C: Measures finalized for removal for 2019.
o Appendix 1, Table Group D: Quality measures with finalized substantive changes for 2019.
o For 2019, CMS finalized the use of the Medicare Spending Per Beneficiary (MSPB) measure, the Total Per Capita Cost (TPCC) measure and 8 Episode-Based cost measures, which are listed in Table 36.
• Improvement Activities
o Appendix 2: Table A: New Improvement Activities for 2019
o Appendix 2: Table B: Changes to previously approved Improvement Activities
• CMS finalized multiple proposed policies related to QCDRs that would take effect in 2020, including:
o An updated definition to ensure QCDRs have clinical expertise in medicine and quality measure development
o A requirement that the QCDR must have at least 25 participants by January 1 of the year prior to the performance period
o A longer, but earlier QCDR self-nomination period (July 1-Sept. 1, rather than the current Sept. 1-Nov 1).
o Applying select criteria used under the Call for Measures Process when considering QCDRs
o CMS is also considering proposing to require reliability and feasibility testing as an added criteria in order for a QCDR measure to be considered for MIPS in future rulemaking
o CMS did NOT finalize, at this time, its proposal to require QCDR measure owners to agree to enter into a license agreement with CMS permitting any approved QCDR to submit data on the QCDR measure for purposes of MIPS. Rather, it is retaining its existing policy that QCDR vendors may seek permission from another QCDR to use an existing measure that is owned by the other QCDR.
o Note that CMS is requesting additional feedback on multiple issues in this section.
Advanced APMs & PTAC. In addition to finalizing most of the Other Payer Advanced APM proposals, CMS received comments that it should accelerate the availability of models and that there continues to be a lack of opportunities for specialists and non-physician. In reply, CMS cited increasing opportunities to participate in Advanced APMs, including in the BPCI Advanced model, the Maryland Total Cost of Care program, and stated that they are also “in the process of developing several new APMs and Advanced APMs, and continue to work with stakeholders on new models.” Stakeholders also expressed concern at the lake of uptake at CMMI of models recommended by PTAC. CMS stated that it understands the value of PTAC, noted that “while it seems unlikely that all of the features of any PTAC-reviewed proposed model will be tested exactly as presented in the proposal, certain features of proposed models may be incorporated into new or existing models.” Finally, the agency declined to accept a recommendation that the Secretary must reply to PTAC recommendations within 60-days (or any deadline).
QPP 2017 Performance and 2019 Impacts
• For the 2017 performance period, the mean score was 74.01 points and the median score was 88.97 points.
• CMS estimates that between 165,000 and 220,000 eligible clinicians would become QPs based on 2019 performance, qualifying for aggregate total APM incentive payments of approximately $600 million to $800 million for the 2021 payment year.
• CMS estimates that 97.8 percent of MIPS eligible clinicians will participate in MIPS, and of those, 91.2 percent are expected to receive positive or neutral payment adjustments.
• CMS declined to provide estimates regarding QPP participation by specialty.
Appropriate Use Criteria (AUC)
• Expands the definition of an applicable setting to include independent diagnostic testing facilities;
• Creates significant hardship exceptions from the AUC requirements that are specific to the AUC program and independent of other Medicare programs;
• Establishes the coding methods, to include G-codes and modifiers, to report the required AUC information on Medicare claims; and
• Allows non-physicians, under the direction of an ordering professional, to consult with AUC when the consultation is not performed personally by the ordering professional.
• Clarifies that the AUC consultation information must be reported on all claims for an applicable imaging service (e.g., if separate, both the technical and professional claim must include the AUC information).
Medicare Shared Savings Program (MSSP)
• To reduce burden, CMS finalized its proposal to eliminate 9 measures and to add 2 measures to the Shared Savings Program quality measure set. The net result of the final policies included in this final rule is a set of 23 measures on which ACOs’ quality performance will be assessed for performance years during 2019 and subsequent performance years (compared to 31 measures used in 2018)
• In a separate section of this rule, CMS also addresses a subset of changes to the Medicare Shared Savings Program (MSSP) for ACOs proposed in the August 2018 proposed rule “Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations Pathways to Success” (see fact sheet) and addresses various other revisions designed to update program policies under the MSSP. In order to ensure continuity of participation and finalize time-sensitive program policy changes for currently participating ACOs, CMS finalized these and other policies:
o A voluntary 6-month extension for existing ACOs whose participation agreements expire on December 31, 2018, and the methodology for determining financial and quality performance for this 6-month performance year from January 1, 2019, through June 30, 2019.
o Promoting interoperability among ACO providers by adding a new Certified EHR Technology (CEHRT) threshold criterion to determine ACOs’ eligibility for program participation and retiring the current MSSP quality measure on the percentage of eligible clinicians using CEHRT.
o Allowing beneficiaries who voluntarily align to a Nurse Practitioner, Physician Assistant, Certified Nurse Specialist, or a physician with a specialty not used in assignment to be prospectively assigned to an ACO if the clinician they align with is participating in an ACO, as provided for in the Bipartisan Budget Act of 2018.
o Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.
o Revising the definition of primary care services used in beneficiary assignment.