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CMS Announces New Medicaid Opportunity to Expand Mental Health Treatment Services

CMS Announces New Medicaid Opportunity to Expand Mental Health Treatment Services

The Centers for Medicare & Medicaid Services (CMS) recently sent a letter to State Medicaid Directors outlining existing and new opportunities for states to design innovative service delivery systems for adults with serious mental illness (SMI) and children with serious emotional disturbance (SED). The letter includes a new opportunity for states to receive authority to pay for short-term residential treatment services in an institution for mental disease (IMD) for these patients. CMS believes these opportunities offer states the flexibility to make significant improvements on access to quality behavioral health care.

Medicaid is the single largest payer of behavioral health services, including mental health and substance use services in the U.S. By one estimate, more than a quarter of adults with a serious mental illness rely on Medicaid. About 10.4 million adults in the U.S. had an SMI in 2016, but only 65 percent received mental health services in that year. Serious mental health conditions can have detrimental impacts on the lives of individuals with SMI or SED and their families and caregivers. Since these conditions often arise in adolescence or early adulthood and often go untreated for many years, individuals with SMI or SED are less likely to finish high school and attain higher education, disrupting education and employment goals.

“More treatment options for serious mental illness are needed, and that includes more inpatient and residential options. As with the SUD waivers, we will strongly emphasize that inpatient treatment is just one part of what needs to be a complete continuum of care, and participating states will be expected to take action to improve community-based mental health care,” said Health and Human Services Secretary Alex Azar. “There are effective methods for treating the seriously mentally ill in the outpatient setting, which have a strong track record of success and which this administration supports. We can support both inpatient and outpatient investments at the same time. Both tools are necessary, and both are too hard to access today.”

CMS currently offers states the flexibility to pursue similar demonstration projects under Section 1115 (a) of the Social Security Act, regarding substance use disorders (SUDs), including opioid use disorder. To date, CMS has approved this authority in 17 states, where it is already improving outcomes for beneficiaries. For example, early results in Virginia show a 39 percent decrease in opioid-related emergency room visits, and a 31 percent decrease in substance-use related ER visits overall after implementation of the demonstration. With this new opportunity, CMS will be able to offer a pathway forward to the 12 states who have already expressed interest in expanding access to community and residential treatment services for the full continuum of mental health and substance use disorders. About a quarter of individuals with SMI have a co-occurring SUD.

States participating in the SMI/SED demonstration opportunity will be expected to commit to taking a number of actions to improve community-based mental health care. These commitments to improving community-based care are linked to a set of goals for the SMI/SED demonstration opportunity and will include actions or milestones to ensure good quality of care in IMDs, to improve connections to community-based care following stays in acute care settings, to ensure a continuum of care is available to address more chronic, on-going mental health care needs of beneficiaries with SMI or SED, to provide a full array of crisis stabilization services, and to engage beneficiaries with SMI or SED in treatment as soon as possible. States are encouraged to build on the opportunities for innovative service delivery reforms discussed in the first part of this letter and summarized below in order to achieve these milestones and goals.

Through this demonstration opportunity, federal Medicaid reimbursement for services will be limited to beneficiaries who are short-term residents in IMDs primarily to receive mental health treatment. CMS will not approve a demonstration project unless the project is expected to be budget neutral to the federal government.

States will also be expected to report information detailing actions taken to achieve the milestones and goals of these demonstrations as well as data and performance measures identified by CMS as key indicators of progress toward meeting the goals of this initiative.

In addition to the 1115 demonstration opportunity the letter also describes strategies under existing authorities to support innovative service delivery systems for adults with SMI and children with SED, that address the following issues:

  • Earlier identification and engagement in treatment, including improved data-sharing between schools, hospitals, primary care, criminal justice, and specialized mental health providers to improve communications;
  • Integration of mental health care and primary care that can help ensure that individuals with SMI or SED are identified earlier and connected with the appropriate treatment sooner;
  • Improved access to services for patients across the continuum of care including crisis stabilization services and support to help transition from acute care back into their communities;
  • Better care coordination and transitions to community-based care; and
  • Increased access to evidence-based services that address social risk factors including services designed to help individuals with SMI or SED maintain a job or stay in school.

CMS announced this new demonstration opportunity following the publication of the Medicaid Managed Care proposed rule. States identified key concerns in the 2016 final rules limitation regarding 15-day length of stay for managed care beneficiaries in an IMD. CMS did not propose any changes to this requirement at this time; however, CMS is asking for comment from states for data that could support a revision to this policy. Meanwhile, this new demonstration opportunity will give interested states the ability to seek federal authority to have greater flexibility to pay for residential treatment services in an IMD as part of broader delivery system improvements.

For more information, please visit: https://www.medicaid.gov/federal-policy-guidance/downloads/smd18011.pdf

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Evaluating and Managing the E/M Codes for 2019 and Beyond

Evaluating and Managing the E/M Codes for 2019 and Beyond

Editor’s Note: This article is the first in a series of articles about notable changes in the 2019 Physician Fee Schedule Final Rule.

In the 2019 Physician Fee Schedule (“PFS”) Proposed Rule, the Centers for Medicare and Medicaid Services (“CMS”) proposed some major changes to the PFS, including changes to the way Evaluation and Management (“E/M”) services are reimbursed. The PFS Final Rule[1] contains some good news and bad news. The good news . . . CMS isn’t making any of the major changes it proposed in 2019. The bad news . . . they plan on making some big changes over the next few years.

<<Quick Summary: 2019 Medicare Physician Fee Schedule and Quality Payment Program Final Rule>>

Proposal

CMS proposed to collapse several levels of E/M Codes into one reimbursement level with add-on codes for certain prolonged or complex visits.

Final Rule

CMS is reducing some documentation redundancies for 2019, but it is not finalizing most of the payment proposals described above until 2021.

The Details

Currently, there are 3 to 5 levels of E/M codes depending on the practice setting (3 to 4 in facility settings and 5 for outpatient or office settings). These codes are billed based on the relative complexity of the E/M service provided, as determined in accordance with either the 1995 or 1997 guidelines issued by CMS.[2] The higher the level of E/M service (and associated relative time and resources required to deliver those services), the higher the reimbursement. According to CMS, E/M codes represent approximately 40 percent of allowed charges for PFS services, and outpatient/office visit E/M codes represent about 20 percent of total PFS allowed charges. Despite the frequency with which E/M services are performed and billed, there are a number of complexities surrounding how they are billed and the documentation required for each level of E/M code.

In an effort to alleviate this burden, CMS proposed to collapse the reimbursement for E/M level 2 through level 5 codes into a single reimbursement amount. In addition, CMS proposed to allow two new add-on codes to represent prolonged services and services with a relatively high degree of complexity. Noting the extensive time and resources that will be needed to adjust to the new coding regime, CMS has delayed the effective date of these rules until 2021. There’s time to prepare for the new E/M coding regime, and it may be altered some between now and 2021, but below is a brief overview of the finalized changes for 2021.

Collapsing Reimbursement for Levels 2-4. Importantly, CMS decided not to change the E/M codes themselves but instead chose to pay the same base reimbursement for E/M code levels 2 through 4.[3] In theory, this will reduce the level of documentation required because physicians will only need to meet the documentation requirements for a level 2 E/M code. However, it will also result in a reduction in reimbursement for many physicians who ordinarily bill higher level E/M codes, unless they also bill for one of the new add-on codes discussed below. Despite the changes in reimbursement levels, physicians do not necessarily have to change how they perform and document E/M services. In fact, CMS expects that physicians will continue to document and bill as they normally would. Noting that other government and private payors (including Medicaid, Blue Cross & Blue Shield, etc.) may continue to use the existing coding structure—or would at least need time to adjust to new coding regimes — CMS decided to retain the existing coding structure, changing the reimbursement only.

Add-On Codes. To account for the reduction in reimbursement associated with the new combined reimbursement rate for E/M levels 2 through 4 and to better align reimbursement with the resources utilized in providing E/M services, CMS decided to add two new add-on codes (again, effective 2021) that can be billed with E/M levels 2 through 4. The first is an add-on code for E/M visits for primary care and certain types of specialized medical care. The second is an add-on code to account for additional resources utilized when physicians have extended visits with patients. Despite the addition of these new codes, CMS indicated that there should not be any additional documentation requirements for E/M services.

Reducing Redundant Data Recording (effective 2019). In response to stakeholder feedback, CMS decided to remove the requirement that physicians document the medical necessity of conducting a visit in the patient’s home instead of in the physician’s office.[4] CMS also decided to streamline documentation requirements by allowing physicians to review information already contained in the medical record (review of systems and past, family and/or social history) and update it as needed, rather than re-recording all of the information.

Proposals Not Adopted. CMS decided not to adopt some of its proposals, including proposals to: (1) reduce reimbursement when E/M services are provided on the same day as a procedure; (2) establish separate podiatric E/M codes; and (3) standardize the amounts of practice expense RVUs for E/M codes.

Conclusion

Overall, there are some changes going into effect in just over a month, and others will likely be reshaped and refined over the next two years before they are implemented in 2021. For now, all physicians need to know is that they can continue to document and bill E/M codes as they always have, but in theory with less redundancy in documentation requirements.

Article contributed by Christopher L. Richard with Gilpin Givhan, PC. Gilpin Givhan, PC, is an official partner with the Medical Association.

 

[1] CMS-1693-F, available at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.

[2] 1995 Documentation Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf; 1997 Guidelines for Evaluation and Management Services, available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf.

[3] CMS decided to combine levels 2 through 4 instead of 2 through 5, as originally proposed.

[4] CMS reasoned that this decision is best left to the physician and patient, without applying additional payment rules.

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CMS Releases Physician Payment Rule

CMS Releases Physician Payment Rule

This week CMS released the final physician payment rule for CY 2019. In addition to the changes to the physician fee schedule (slightly higher than the CY 2018 rate), the rule expands payment for telehealth and aligns physician interoperability requirements with hospital requirements and allows more flexibility in the physician quality reporting program. The rule finalizes a consolidated payment rate for evaluation and management (E/M) office and outpatient visit levels 2 through 4, while maintaining the payment rate for level 5 E/M visits. It also reduces payment for new Part B drugs and requires hospital outreach laboratories to begin collecting and reporting private payer payment rates and volumes. Finally, the rule will continue to allow non-excepted off-campus provider-based departments of hospitals to bill for non-excepted services on the institutional claim and will maintain payment for non-excepted services at 40 percent of the outpatient prospective payment system amount for CY 2019.

The Medical Association partnered with the American Medical Association to secure the changes.

Removing Restrictions on E/M Coding

CMS finalized several changes to E/M documentation guideline which were strongly supported by the AMA and other members of the Federation:

  • The requirement to document medical necessity of furnishing visits in the home rather than office will be eliminated.
  • Physicians will no longer be required to re-record elements of history and physical exam when there is evidence that the information has been reviewed and updated. In addition,
  • Physicians must only document that they reviewed and verified information regarding chief complaint and history that is already recorded by ancillary staff or the patient.
  • These changes will take effect 1/1/2019.

The Original Proposal Condensing Office Visit Payment Amounts and Documentation Requirements

In the 2019 proposed rule, CMS proposed to implement a single payment rate for level 2 through level 5 office visits and to reduce documentation requirements for this collapsed payment to that of a level 2 CPT visit code. The Agency proposed to continue to use existing CPT structure for office visit codes 99201-99215, though proposed to change CMS guidelines and only enforce certain aspects of the CPT structure by allowing physicians to choose the method of documentation, among the following options:

  • 1995 or 1997 Evaluation and Management Guidelines for history, physical exam and medical decision making (current framework for documentation)
  • Medical decision making only
  • Physician time spent face-to-face with patients
  • CMS had also proposed an add-on code to each office visit performed for primary care purposes and an add-on code for specialities with inherently complex E/M visits
  • CMS relayed that commenters overwhelmingly opposed the Agency’s proposed payment collapse. CMS will not finalize the proposal for CY 2019.

Other Coding/Payment Proposals Related to E/M

The following policies were also opposed and will not be implemented by CMS:

  • Payment reductions by 50 percent for office visits that occur on the same date as procedures (or a physician in the same group practice). The AMA brought attention to the fact that duplicative resources have already been removed from the underlying procedure through the current valuation process.
  • In addition, CMS proposed to no longer allow for podiatry to report CPT codes 99201-99215 and instead would use two proposed G-codes for podiatry office visits. As well as a new prolonged service code that would have been implemented to add-on to any office visit lasting more than 30 minutes beyond the office visit (ie, hour long visits in total).
  • Condensed practice expense payment for the E/M office visits, by creating a new indirect practice expense category solely for office visits, overriding the current methodology for these services by treating Office E/M as a separate Medicare Designated Specialty. This change would also have resulted in the exclusion of the indirect practice costs for office visits when deriving every other specialty’s indirect practice expense amount for all other services that they perform, which would have resulted in large changes in payment for many specialties (ie a greater than 10 percent payment reduction for chemotherapy services).

Download the CMS Factsheet.

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CMS Updates LCD Determination Process

CMS Updates LCD Determination Process

On Oct. 3, 2018, the Centers for Medicare and Medicaid Services announced updates to Chapter 13 of the Medicare Program Integrity Manual, which deals with Local Coverage Determinations. According to CMS, the updates are intended to “increase transparency and patient engagement.”[1]  These changes call for informal meetings with interested parties before a formal request is submitted to the Medicare Administrative Contractor.  Educational meetings can be held in local jurisdictions and can be either in-person, teleconference or web-based.  Additionally, the changes to the manual set forth a roadmap for how the MAC issues an LCD.

LCDs are issued by MACs when there is no national determination on whether an item or service is covered. The idea is that the regional MACs will take into account local variations in the practice of medicine when issuing the LCD. For example, Palmetto GBA, Alabama’s MAC for Medicare Part A and B has issued an LCD on allergy testing (L33417).

According to a Medicare Learning Network publication[2], CMS’s updates were a result of feedback from providers and healthcare associations who were concerned that beneficiaries were not receiving necessary products and procedures due to deficiencies in the LCD process, such as notification of revisions to and drafting of LCDs. The new LCD process is intended to allow for more interaction with stakeholders before and during LCD development.

The “Roadmap”

1)         Requests for LCD

MACs will consider requests from beneficiaries residing or receiving care in the MAC’s jurisdiction, health care professionals doing business in the MAC’s jurisdiction or any interested party doing business.

A request is deemed complete if the request:

  • Is in writing and is sent to the MAC via e-mail, facsimile or written letter.
  • Clearly identifies the statutorily-defined Medicare benefit category to which the item or service applies.
  • Identifies the language the requestor wants in an LCD.
  • Includes justification supported by peer-reviewed evidence. Full copies of the published evidence must be included.
  • Addresses relevance, usefulness, clinical health outcomes, or the medical benefits of the item or service.
  • Fully explains the design, purpose, and/or method as appropriate of using the item or service for which the request is made.

2)         Consideration of the LCD

The new guidelines suggest that MACs supplement the requests or proposed LCDs with clinical guidelines, consultation with experts, medical associations or other health care professionals.  This information is to be summarized prior to drafting or finalizing the LCD.

3)         Publication

A proposed LCD will be published on the Medicare Coverage Database (MCD) website at https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

Once published, MACs will allow 45 days for public comment.  There are some exceptions to the publication requirement.

4)         Contractor Advisory Committee (CAC)

A CAC will be established from each state and will be composed of healthcare professionals, beneficiary representatives and representatives of medical organizations.  The purpose of the CAC is to assist in the evaluation of the evidence in developing LCDs and communicate between the MACs and healthcare community.  This is an advisory committee with the ultimate authority residing with the MACs.

5)         Open Meetings

After the LCD publication, the MAC will hold an open meeting to discuss the rationale and evidence supporting the LCD.  Interested parties can also make presentations at these meetings.  The date and location of the meetings must be publicized by the MAC.

6)         Publication of Final Determination

After the close of the comment period and the required public meeting, the final LCD and Response to Public Comment will be published on the MCD (see link above).  MACs must respond to all comments received during the comment period.

7)         Notice Period

The date the final LCD is published on the MCD marks the beginning of the required notice period of at least 45 days before the LCD can go into effect.  If the notice period is not extended by the MAC beyond the 45 days, the LCD is effective on the 46th calendar day.

Additional changes include the retirement (or expiration) of all proposed polices if not finalized within one year after the original posting date and a removal of all ICD and CPT codes from LCDs.

For more information on the changes to Chapter 13, visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf.

[1] CMS Accelerates Innovation and Promotes Patient Access to Medical Technology, https://www.cms.gov/newsroom/press-releases/cms-accelerates-innovation-and-promotes-patient-access-medical-technology

[2] https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf

Angie Cameron Smith is an attorney at Burr & Forman LLP practicing within the firm’s Health Care Industry Group. Burr & Forman LLP is a partner with the Medical Association.

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Big Changes Proposed for Evaluation and Management Services

Big Changes Proposed for Evaluation and Management Services

It’s been more than 20 years since the 1997 revisions to Evaluation and Management guidelines, which focus mainly on physical examination. The 2019 proposed changes provide practitioners a choice in the basis of documenting E/M visits; alleviating the burdens and focusing attention on alternatives that better reflect the current practice of medicine. The implementation of electronic medical records has allowed providers to document more information, yet repetitive templates, cloning and other workflows have pushed the envelope on compliance in documenting the traditional elements of the visit.

The proposed changes to Evaluation and Management were released in the Federal Register on July 27. The Center of Medicare and Medicaid Services is taking comments until Sept. 10, before releasing the Final 2019 Medicare Fee Schedule.

The CPT guidelines are not changing! The American Medical Association is the author of the CPT books, and there is no change in the 1995 or 1997 guidelines for E/M documentation. Medical necessity remains the overarching criteria to select a level of service. There are three proposals to reduce documentation burdens related to CMS:

Proposal One

Simplify History and Exam Documentation, allowing the physicians to focus on changes in health and allow ancillary staff to document chief complaint and history without the physician re-entering it.

Proposal Two

Remove History and Exam from E/M level decision. Currently, history and exam are two of three required elements along with medical decision-making. Medical decision-making would be the sole determinant of E/M level. Providers could use face-to-face time as a determining factor when selecting an E/M service level.

Proposal Three

Pay a single rate for Level E/M visits for the reduced burden in documentation and coding guidelines. Proposals one and two will be a package deal in proposal three. The tables below reflect the proposed payment rates.

Table A – New Patient E/M: Non-facility

Code        2018 Payment Rate     CY 2018 New Payment Rate

99201 $45 $44
99202 $76 $135
99203 $110 $135
99204 $167 $135
99205 $211 $135

 

Table B – Established Patient E/M: Non-facility

Code           2018 Payment Rate             CY 2018 New Payment Rate

99211 $22 $24
99212 $45 $93
99213 $74 $93
99214 $109 $93
99215 $148 $93

 

There are two add-on codes proposed, including one for primary care to cover inherent complexity. The primary care add-on code is GPC1X. It can only be utilized by primary care. By adding the G code to Medicare claims, internal medicine and family practice can actually earn up to five percent more revenue and reduce documentation efforts.

The add-on code available to a list of ten specialties is GPC0X. The specialties were chosen due to the inherent complexity related to E/M. The specialties eligible for this add-on code are: endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, cardiology or interventional pain. The big loser in this proposal is pulmonary medicine, with a reduction of 6.2 percent in revenue projected by Part B News. The big winner is urology, with a projected increase in revenue of 22 percent with the add-on code.

As a certified coder, I believe the reduction in documentation is a positive change. Most physicians were not educated on CPT coding as part of their clinical training. Physicians want to be compliant, but the guidelines are too complex to analyze during each encounter. The ancillary staff should be trained to effectively gather pertinent information to support the physician. This would allow physicians to focus on the clinical needs of the patient. CMS expects medical necessity to prevail and each encounter to stand alone in relation to the full medical record.

A proposal for 2019, we aren’t hearing about is an E/M multiple procedure payment adjustment related to duplicative resource costs when an E/M is visited and a procedure with global periods are furnished on the same day. CMS would reduce the E/M payment by 50 percent.

Administrators should review the proposed options for documentation to understand the effect on their practice. If your practice has the potential to see a negative adjustment without the option to utilize an add-on code, you should analyze the E/M dispersion pattern to understand the financial impact to your practice. For the most part, the proposed changes are positive in an effort to reduce the burden of redundant documentation. We should continue to hear much more information regarding this game-changing proposal particularly after the comment period ends on Sept. 10. The final 2019 fee schedule will be released around the first week of November. Stay tuned!

If you would like to send a comment to CMS on these changes (and we suggest you do), go to https://www.federalregister.gov/documents/2018/07/27/2018-14985/medicare-program-revisions-to-payment-policies-under-the-physician-fee-schedule-and-other-revisions.

Article contributed by Tammie Lunceford, Healthcare and Dental Consultant, Warren Averett Healthcare Consulting Group. Warren Averett is an official partner with the Medical Association.

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Brookwood Baptist Medical Center Medicare Certification Extended

Brookwood Baptist Medical Center Medicare Certification Extended

Brookwood Baptist Medical Center, the second largest hospital in the metro Birmingham area, received an 11th-hour reprieve Thursday night with regulators from the Centers for Medicare and Medicaid Services accepted the facility’s action, thus allowing the hospital to continue its Medicare and Medicaid billing privileges. However, the facility is not out hot water just yet.

“The immediate jeopardies have been removed at this time, but the hospital remains in noncompliance status and must work to correct the deficiencies cited to protect the health and safety of the facility’s patients,” according to a CMS statement, which also noted the survey review process can be extended over the next 60 days.

Brookwood Baptist CEO Keith Parrott said the hospital will continue to fully participate in the Medicare and Medicaid programs without further interruption. Even a short-term interruption in participation could pose a significant financial challenge given the large amount of revenue and jobs at stake. Parrott also said the hospital will be resurveyed in the future.

In May, Brookwood Baptist received a notice stemming from an April incident in its psychiatric unit. The May CMS order was rescinded after a follow-up inspection determined Brookwood Baptist was in compliance with guidelines. Brookwood Baptist received a termination notice in late July that gave the hospital until Aug. 9 to become compliant with CMS guidelines pertaining to government body, patients’ rights and nursing services.

It was the second notice the hospital has received this year.

According to CMS, Brookwood’s immediate jeopardy notice was based on “the hospital’s failure to staff to implement its elopement policy resulting in the death of one patient; failure of staff in the telemetry monitoring unit to notify registered nurses of a patient who had no heart rate for 15 minutes and subsequently died; and a failure of staff to notify the physician of a patient’s low blood pressure readings resulting in the patient being found unresponsive and not breathing.

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CMS Publishes 2019 Physician Fee Schedule

CMS Publishes 2019 Physician Fee Schedule

UPDATED JULY 27, 2018: CMS Overhauls Office Visit Pay In Proposed 2019 Physician Fee Rule

CMS is proposing to overhaul how Medicare pays for office visits and how doctors document those visits in what Administrator Seema Verma said would be “one of the most significant reductions in provider burden ever taken by any administration.” The change, which is included in the proposed 2019 Physician Fee Schedule released Thursday, July 12, would simplify coding and create a single payment amount for “evaluation and management” visits, or E/M visits, and some specialists could see payment reductions as a result. The Medical Association is continuing to analyze the proposed fee schedule to see what potential impact it will have on physician practices in Alabama. We will keep you posted as more information becomes available.

In what industry lobbyists said would be another significant change, the proposed rule also seeks to establish new payment codes for two new virtual services: telephone “check-ins” between clinicians and beneficiaries, and the remote evaluation of photos or videos that a patient submits to a clinician.

In addition, the proposed rule would enact provisions of the Bipartisan Budget Act of 2018 to expand telehealth services for beneficiaries with end-stage renal disease receiving home dialysis and beneficiaries with acute stroke. CMS was expected to use its 2019 pay rules to expand telehealth in Medicare.

Verma touted the proposed overhaul of the E/M payment system as a way to reduce the time that doctors spend “copying, pasting, and clicking” to comply with the current system’s onerous documentation requirements.

“Doctors should not be spending time typing in information strictly to bill a certain level of code,” Verma said on a conference call with reporters.

The proposed rule would change the current system, which has four sets of documentation requirements for physicians, to a system with a single set of documentation requirements. It would establish a single, blended rate for E/M visits–a change that Verma said could result in a 1-2 percent pay reduction for doctors who typically bill at the higher rates under the existing system.

“We believe any negative payment adjustments will be outweighed by the dramatic reduction in administrative burden, allowing clinicians more time to spend with their patients,” Verma said.

The proposed rule also retains a so-called site-neutral policy under which certain off-campus hospital outpatient departments are paid 40 percent of what they would have received under the Hospital Outpatient Prospective Payment System. The American Hospital Association released a statement calling that portion of the proposed rule short-sighted.

The proposed rule includes a request for information on how CMS could make health care costs more transparent. In the 2019 Hospital Inpatient Prospective Payment System proposed rule, CMS said it would require hospitals to post their standard charges online, but the agency said Thursday that it thinks more can be done on price transparency and is seeking suggestions from the public on how it can better inform patients about out-of-pocket costs.

Other provisions in the proposed rule include:

  • Reducing the level of physician supervision required for services provided by radiologist assistants.
  • Allowing payment for communication technology-based services and remote evaluation services furnished by rural health clinics and federally qualified health centers.
  • Discontinuing functional status reporting requirements for outpatient therapy.
  • Implementing a statutory pay reduction for services provided by therapy assistants.
  • Seeking comments on how to combat opioid use disorder in Medicare.

The proposed rule’s conversion factor, a value used in CMS’ formula to calculate payment rates, is $36.05, up from the 2018 conversion factor of $35.99. Public comments on the proposed rule are due Sept. 10.


CMS has published the proposed Physician Fee Schedule Rule for 2019, which includes provisions for the Quality Payment Program for 2019 as well as the physician fee schedule. Medical Association staff is reviewing the proposed rule and would appreciate any comments you might have concerning its contents.

This is a brief summary of the key Medicare Fee Schedule proposals:

  • With the budget neutrality adjustment to account for relative value changes, as required by law, the proposed 2019 PFS conversion factor is $36.05, a slight increase above the 2018 PFS conversion factor of $35.99.
  • CMS has proposed to collapse payment for office and outpatient visits.  New patient office visit (99202-99205) payments would be blended to be $135. Established office visits (99212-99215) would be blended to be paid at $93. New codes would be created to provide add-on payments to office visits for specific specialties ($9) and primary care physicians ($5).
  • To replace existing documentation guidelines, CMS proposes to allow use of (1) 1995 or 1997 documentation guidelines; (2) medical decision-making or (3) time. Documentation for history and exam will focus on interval history since last visit. Physicians will be allowed to review and verify certain information in the medical record entered by ancillary staff or the beneficiary, rather than re-entering the information.
  • When physicians report an E/M service and a procedure on the same date, CMS proposes to implement a 50% multiple procedure reduction to the lower paid of the two services.
  • CMS will implement new CPT codes and payment for remote monitoring and interprofessional consultations.
  • CMS updated supplies and equipment pricing. The re-pricing of antigens has a significant impact on allergy and immunology payments, with an estimated 6% reduction for the specialty.

Here are some of the highlights of the Merit-based Incentive Payment System (MIPS) proposals:

  • Retain the low-volume threshold but add a third criteria of providing fewer than 200 covered professional services to Part B patients.
  • Retaining bonus points for: care of complex patients, end-to-end reporting, small practices
  • Allowing eligible clinicians to opt-in if they meet one or two, but not all, of the low volume threshold criterion.
  • Consolidating the low-volume threshold determination periods with the determination period for identifying a small practice.
  • Eliminate the base and performance categories and reduced the number of measures in the Promoting Interoperability category.
  • Require Eligible clinicians to move to 2015 CEHRT.
  • Providing the option to use facility-based scoring for facility-based clinicians.
  • For 2019 performance year the weights are: Quality  – 45%; Cost- 15%; Promoting Interoperability – 25%; Improvement Activities- 15%

As a reminder, the Bipartisan Budget Act of 2018 provided additional flexibility for CMS on several MIPS issues including:

  • Excluding Medicare Part B drug costs from MIPS payment adjustments and from the low-volume threshold determination;
  • Allowing CMS to reweight the cost performance category to not less than 10 percent and not more than 30 percent for 2019-2021 performance years; and
  • Allowing CMS flexibility in setting the performance threshold for performance years 2019-2021 to provide a gradual and incremental transition for physicians.

 

 

 

 

CMS has provided Fact Sheets on the major components of the rule which are available at the following links:

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-12-2.html

https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2019-QPP-proposed-rule-fact-sheet.pdf .

In addition, the specialty impact table from the rule is attached for your information.

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CMS Releases Proposed Rule for 2019 Medicare Quality Payment Program

CMS Releases Proposed Rule for 2019 Medicare Quality Payment Program

On July 12, the Centers for Medicare & Medicaid Services released its proposed policies for Year 3 (2019) of the Quality Payment Program via the Medicare Physician Fee Schedule Notice of Proposed Rulemaking. The provisions included in the NPRM are reflective of the feedback we received from many stakeholders, and continue to provide additional flexibilities to reduce burden and smooth the transition, where possible, so that doctors and other clinicians can spend more time with patients.

Key proposals for Year 3 of the Quality Payment Program include:

  • Expanding the definition of Merit-based Incentive Payment System (MIPS) eligible clinicians to include new clinician types (physical therapists, occupational therapists, clinical social workers, and clinical psychologists).
  • Adding a third element (Number of Covered Professional Services) 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.
  • Providing the option to use facility-based scoring for facility-based clinicians that don’t require data submission.
  • Modifying the MIPS Promoting Interoperability (formerly Advancing Care Information) performance category to support greater electronic health record (EHR) interoperability and patient access while aligning with the proposed new Promoting Interoperability Program requirements for hospitals.
  • Moving clinicians to a smaller set of Objectives and Measures with scoring based on performance for the Promoting Interoperability performance category.
  • Continuing the small practice bonus, but including it in the Quality performance category score of clinicians in small practices instead of as a standalone bonus.
  • Streamlining the definition of a MIPS comparable measure in both the Advanced Alternative Payment Models (APMs) criteria and Other Payer Advanced APM criteria to reduce confusion and burden amongst payers and eligible clinicians submitting payment arrangement information to CMS.
  • Updating the MIPS APM measure sets that apply for purposes of the APM scoring standard.
  • Increasing flexibility for the All-Payer Combination Option and Other Payer Advanced APMs for non-Medicare payers to participate in the Quality Payment Program.
  • Updating the Advanced APM Certified EHR Technology (CEHRT) threshold so that an Advanced APM must require that at least 75% of eligible clinicians in each APM Entity use CEHRT.
  • Extending the 8% revenue-based nominal amount standard for Advanced APMs through performance year 2024.

Additionally, as a result of our Human-Centered Design research, we’ve included new language that more accurately reflects how clinicians and vendors interact with MIPS. We look forward to your feedback on this approach. Please note that the official commenting mechanisms are outlined below.

Submit Comments by September 10

CMS is seeking comment on a variety of proposals in the NPRM. Comments are due by September 10, 2018.

You must officially submit your comments in one of the following ways:

  • Electronically, through Regulations.gov
  • Regular mail
  • Express or overnight mail
  • By hand or courier

For More Information

To learn more about the PFS NPRM and the Quality Payment Program proposals, review the following resources:

  • Press release – provides more details about the announcement
  • Fact sheet – offers an overview of the proposed policies for 2019 (Year 3) and compares these policies to the current 2018 (Year 2) requirements
  • Webinar – overview of the proposed rule for the 2019 performance period with the opportunity to ask questions

To learn more about the Quality Payment Program, visit: https://qpp.cms.gov.

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CMS Rebrands Meaningful Use to Highlight New Changes

CMS Rebrands Meaningful Use to Highlight New Changes

As part of the annual Medicare payment update proposal, Centers for Medicare and Medicaid along with the Trump Administration plan to rebrand Meaningful Use to reduce burdens and unnecessary regulations while emphasizing data sharing across providers.

The new Meaningful Use program, now called “Promoting Interoperability,” aims to reduce reporting measures and initiate a stronger push for price transparency among hospitals.

CMS announced the change as part of a proposed rule issued on April 24 that will transform the EHR Incentive Programs, as well as introduce changes to Medicare payment policy rates under the Inpatient Prospective Payment System (IPPS) and the Long-Term Care Hospital (LTCH) Prospective Payment System (PPS).

“We seek to ensure the health care system puts patients first,” said Administrator Seema Verma. “Today’s proposed rule demonstrates our commitment to patient access to high-quality care while removing outdated and redundant regulations on providers.”

The new program doesn’t do away with all current meaningful use requirements, including that providers use the 2015 edition of certified electronic health record technology in 2019. The 2015 edition of technology aligns with the provisions of the 21st Century Cures Act that calls for using open application programming interfaces in EHRs.

Using those APIs, developers could allow patients to collect all their health data in one place. This is similar to what Apple is already doing with its Health app. Starting this spring, the app will let patients of certain health systems download their health records from patient portals and store the information on their iPhones.

This kind of data-sharing between the patient and provider could ultimately cut duplicative testing and improve the continuity of care, according to the CMS.

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Updates to 2017 Extreme and Uncontrollable Circumstances Policy for MIPS Clinicians

Updates to 2017 Extreme and Uncontrollable Circumstances Policy for MIPS Clinicians

The Centers for Medicare & Medicaid Services has updated its Extreme and Uncontrollable Circumstances policy for the 2017 Merit-based Incentive Payment System (MIPS) transition year to include counties affected by Hurricane Nate and additional counties affected by the California wildfires. CMS understands that living in an area where these disasters took place may impact your resources to collect or submit data on time.

The data submission period for the 2017 transition year of MIPS is January 2- March 31, 2018. MIPS eligible clinicians in Federal Emergency Management Agency (FEMA) designated areas affected by Northern California wildfires and Hurricanes Harvey, Irma, Maria and Nate will be automatically identified. No action is required. However, if you are automatically identified but still choose to submit data on two or more MIPS performance categories (either as an individual or group), you’ll be scored on those performance categories and your MIPS payment adjustment will be based on your final score.

MIPS eligible clinicians in these newly identified designated areas for Hurricane Nate and the California Wildfires are now covered by the Extreme and Uncontrollable Circumstances policy:

  • Alabama: Autauga, Baldwin, Choctaw, Clarke, Dallas, Macon, Mobile, and Washington
  • Mississippi: George, Greene, Hancock, Harrison, Jackson, and Stone
  • California: Butte, Lake, Mendocino, Napa, Nevada, Orange, Santa Barbara, Solano, Sonoma, Ventura, and Yuba

To learn more about the policy and all the designated areas for the 2017 transition year, view the interim final rule with comment period and the Extreme and Uncontrollable Circumstances Policy for MIPS in 2017 Fact Sheet.

Questions? The Quality Payment Program Service Center can be reached at 1-866-288-8292 (TTY 1-877- 715- 6222), Monday through Friday, 8:00 AM-8:00 PM Eastern time or by email at: QPP@cms.hhs.gov.

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