Digesting the Medicare Physician Fee Schedule for 2019

CMS issued the final rule on Nov. 1.

The Centers for Medicare & Medicaid Services (CMS) final rule includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (MPFS) on or after Jan. 1, 2019.

CMS has finalized a number of documentation, coding, and payment changes to reduce administrative burdens and improve payment accuracy for office/outpatient evaluation and management (E&M) visits over several years. For CYs 2019 and 2020, they are implementing several new documentation policies, while other changes to documentation, coding, and payment will be implemented in CY 2021. 

For CY 2019 and CY 2020, CMS will continue the current coding and payment structure for E&M office/outpatient visits, and practitioners should continue to use either the 1995 or 1997 E&M documentation guidelines to document E&M visits billed to Medicare.

For CY 2019 and beyond, CMS is finalizing the following policies:

• Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit;
• For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so;

• Additionally, for E&M office/outpatient visits for new and established patients, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information; and

• Removal of potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team for E&M visits furnished by teaching physicians.

Beginning in CY 2021, CMS will further reduce administrative burdens with the implementation of payment, coding, and other documentation changes. Payment for E&M office/outpatient visits will be simplified, and payment will vary primarily based on attributes that do not require separate, complex documentation. Specifically, for CY 2021, CMS is finalizing the following policies:

• Reduction in the payment variation for E&M office/outpatient visit levels by having providers pay a single rate for E&M office/outpatient visit levels 2 through 4 for established and new patients, while maintaining the payment rate for E&M office/outpatient visit level 5 in order to better account for the care and needs of complex patients;

• Permitting practitioners to choose to document E&M office/outpatient level 2 through 5 visits using medical decision-making (MDM) or time instead of applying the current 1995 or 1997 E&M documentation guidelines, or, alternatively, practitioners could continue using the current framework;

• Beginning in CY 2021, for E&M office/outpatient levels 2 through 5 visits, there will be flexibility in how visit levels are documented: specifically, a choice to use the current framework, MDM, or time. For E&M office/outpatient level 2 through 4 visits, when using MDM or current framework to document the visit, a minimum supporting documentation standard associated with level 2 visits will also apply. For these cases, Medicare would require information to support a level 2 E&M office/outpatient visit code for history, exam, and/or medical decision-making;

• When time is used to document, practitioners will document the medical necessity of the visit, and that the billing practitioner personally spent the required amount of time face-to-face with the beneficiary;

• Implementation of add-on codes that describe the additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care, though they would not be restricted by physician specialty. These codes will only be reportable with E&M office/outpatient level 2 through 4 visits, and their use generally would not impose new per-visit documentation requirements; and

• Adoption of a new “extended visit” add-on code for use only with E&M office/outpatient level 2 through 4 visits to account for the additional resources required when practitioners need to spend extended time with the patient.

CMS is finalizing its proposals to pay separately for two newly defined physicians’ services furnished using communication technology:

• Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012); and

• Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010).

For CY 2019, CMS is finalizing its proposals to add the following codes to the list of telehealth services: G0513 and G0514 (Prolonged preventive service(s)).

Outpatient Physical Therapy and Occupational Therapy Services Furnished by Therapy Assistants

The Bipartisan Budget Act of 2018 requires payment for services furnished in whole or in part by a therapy assistant at 85 percent of the applicable Part B payment amount for the service, effective Jan. 1, 2022. In order to implement this payment reduction, the law requires CMS to establish a new modifier by Jan. 1, 2019.

CMS also is finalizing its proposal to establish two new modifiers – one for physical therapy assistants (PTAs) and another for occupational therapy assistants (OTAs) – when services are furnished in whole or in part by a PTA or OTA. However, CMS is finalizing the new modifiers as “payment” rather than as “therapy” modifiers, based on comments from stakeholders. These will be used alongside the current PT and OT modifiers, instead of replacing them, which retains the use of the three existing therapy modifiers to report all PT, OT, and speech language pathology services that have been used since 1998 to track outpatient therapy services that were subject to the therapy caps. CMS is also finalizing a de minimis standard under which a service is furnished in whole or in part by a PTA or OTA when more than 10 percent of the service is furnished by the PTA or OTA, instead of the proposed definition that applied when a PTA or OTA furnished any minute of a therapeutic service. The new therapy modifiers for services furnished by PTAs and OTAs are not required on claims until Jan. 1, 2020.

Clinical Laboratory Fee Schedule

The Clinical Laboratory Fee Schedule (CLFS) final rule, titled “Medicare Program: Medicare Clinical Diagnostic Laboratory Tests Payment System,” implemented Section 1834A of the Social Security Act, which required extensive revisions to the Medicare payment, coding, and coverage for clinical diagnostic laboratory tests (CDLTs) paid under the CLFS. Beginning Jan. 1, 2018, the payment amount for a test on the CLFS became generally equal to the weighted median of private payor rates determined for the test, based on the data of “applicable laboratories” that is collected during a specified data collection period and reported to CMS during a specified data reporting period. The first data collection period was from Jan. 1 through June 30, 2016, and the first data reporting period was from Jan. 1, 2017 through March 31, 2017, including an additional 60-day enforcement discretion period.

Medicare Shared Savings Program Accountable Care Organizations (ACOs)

The final rule also addresses a subset of changes to the Medicare Shared Savings Program for ACOs proposed in the August 2018 proposed rule “Medicare Program; Medicare Shared Savings Program; Accountable Care Organizations’ Pathways to Success” and other revisions designed to update program policies under the Shared Savings Program. In order to ensure continuity of participation, finalize time-sensitive program policy changes for currently participating ACOs, and streamline the ACO core quality measure set to reduce burden and encourage better outcomes, CMS is finalizing the following policies:

• A voluntary six-month extension for existing ACOs whose participation agreements expire on Dec. 31, 2018, and the methodology for determining financial and quality performance for the six-month performance year extending from Jan. 1 through June 30, 2019;

• 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;

• Revising the definition of primary care services used in beneficiary assignment; and

• Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.

Request for Information on Price Transparency

Under current law, hospitals are required to establish and make public a list of their standard charges. In an effort to encourage price transparency by improving the public accessibility of price information, CMS included a request for information related to price transparency and improving beneficiary access to provider and supplier charge information in the CY 2019 PFS proposed rule. CMS has indicated that it appreciates the input provided by commenters.

Ambulance Fee Schedule Payments

The Bipartisan Budget Act of 2018 extended the temporary add-on payments for ground ambulance services for five years. The three temporary add-on payments include: 

Program Note:

Listen to Tim Powell report on the CMS final rule today on Talk Ten Tuesdays, 10-10:30 a.m. ET.

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