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