Final Rules from CMS Offer Something for Everyone

CMS updated Medicare regulations for 2019

EDITOR’S NOTE: Veteran Washington, D.C. observer Stanley Nachimson reported on the final rules from the Centers for Medicare & Medicaid Services (CMS) during Talk-Ten-Tuesdays today. The following is a transcription of his remarks.

The Centers for Medicare & Medicaid Services (CMS) has been quite busy these last few weeks, getting approval for and publishing a number of critical final rules that will have an impact on documentation, coding, and payments. 

A number of the rules had to do with ways to reduce the prices of drugs and to make changes to the insurance programs operating under the Patient Protection and Affordable Care Act (PPACA). The key topics for our audience were the final rules for the 2019 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP), the Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment Policy, and the Home Health Prospective Payment System (PPS) System Update.

These key rules contain a number of provisions for not only 2019, but several years after that. CMS has emphasized that these rules “reflect a broader Administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation.”

And I want to point out that public comments to CMS on the proposals for these rules resulted in significant changes to the final versions. I have emphasized the importance of the public comment process for proposed regulations, and here we will see the impact that such comments can have.


The Physician PPS

  • For CY 2019 and CY 2020, CMS will continue the current coding and payment structure for evaluation and management (E&M) office/outpatient visits, and practitioners should continue to use either the 1995 or 1997 E&M documentation guidelines to document such services.
  • Office/outpatient visits billed to Medicare are also included (proposed rule would introduce changes starting in 2019).
  • For CY 2019 and beyond, CMS is finalizing the following documentation reduction policies:
    • 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.
    • The requirement to document the medical necessity of a home visit in lieu of an office visit is being eliminated.
    • For visits by 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.
  • E&M coding and payment changes, starting in CY2021, include the following:
    • 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 of level 5) is being introduced in order to better account for the care and needs of complex patients.
    • 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, not be restricted by physician specialty.
    • Permitting practitioners to choose to document E&M office/outpatient level 2 through 5 visits using medical decision-making or time, instead of applying the current 1995 or 1997 E&M documentation guidelines – or, alternatively, practitioners could continue using the current framework.
  • Changes to coding and payment for telehealth and communication technologies include the following:
    • 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).
    • Add the following codes to the list of telehealth services: HCPCS codes G0513 and G0514 (prolonged preventive service(s))

Merit-Based Incentive Payment System (MIPS)

These changes included adding clinicians who are physical therapists, occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and registered dietitians or nutrition professionals, but they are mostly exempt from the electronic health record (EHR) provisions.

Other changes include the following:

  • A simplified scoring process for promoting interoperability, yet a security risk analysis is still required.
  • Promoting interoperability and improvement activities in performance categories is a minimum of a continuous 90-day period within CY 2019, up to and including the full CY 2019 (Jan. 1, 2019 through Dec. 31, 2019).

The new rule also includes a cost category for care episodes, calculated by CMS.


Outpatient PPS

This change applies a Physician Fee Schedule (PFS)-equivalent payment rate for a clinic visit service when provided at an off-campus, provider-based department (PBD) that is paid under the OPPS. CMS estimates this would result in lower copayments for beneficiaries and savings for the Medicare program in an estimated amount of $380 million for 2019, the first year of a two-year phase-in being utilized to implement this policy.

The ASC Covered Procedures List (CPL) is a list of covered surgical procedures that are payable by Medicare when furnished in an ASC. For CY 2019, CMS is finalizing a proposal to include additional CPT codes outside of the surgical code range that directly crosswalk or are clinically similar to procedures within the CPT® surgical code range on the CPL. As a result, CMS is finalizing its proposal to add 12 cardiovascular codes to the ASC CPL and five additional codes as a result of stakeholder comments the agency received.

Additionally, CMS reviewed all procedures added to the ASC CPL within the past three years to reassess recent experience with the procedures in the ASC, and to determine whether such procedures should continue to be on the ASC CPL. CMS is not finalizing any changes to the ASC CPL as a result of that review.

The American Hospital Association (AHA) has stated that it intends to file a lawsuit against CMS for the equivalent payment rate provision, saying that the agency exceeded its authority.



These changes update payment rates for 2019, and include a recognition that the Bipartisan Budget Act of 2018 requires a change in the unit of payment under the HH PPS, going from 60-day episodes of care to 30-day periods of care, to be implemented in a budget-neutral manner on Jan. 1, 2020. Also, for 2020, the Bipartisan Budget Act of 2018 mandated that Medicare stop using the number of therapy visits provided to determine home health payment.

In this rule, CMS is finalizing the implementation of the Patient-Driven Groupings Model, or PDGM, for home health periods of care beginning on or after Jan. 1, 2020. Using patient characteristics to place home health periods of care into meaningful payment categories is more consistent with how home health clinicians differentiate between home health patients in order to provide needed services. The improved structure of this case-mix system would move Medicare towards a more value-based payment system that puts the unique care needs of the patient first, while also reducing the administrative burden associated with the HH PPS.

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Stanley Nachimson, MS

Stanley Nachimson, MS is principal of Nachimson Advisors, a health IT consulting firm dedicated to finding innovative uses for health information technology and encouraging its adoption. The firm serves a number of clients, including WEDI, EHNAC, the Cooperative Exchange, the Association of American Medical Colleges, and No World Borders. Stanley is focusing on assisting health care providers and plans with their ICD-10 implementation and is the director of the NCHICA-WEDI Timeline Initiative. He serves on the Board of Advisors for QualEDIx Corporation. Stanley served for over 30 years in the US Department of Health and Human Services in a variety of statistical, management, and health technology positions. His last ten years prior to his 2007 retirement were spent in developing HIPAA policy, regulations, and implementation planning and monitoring, beginning CMS’s work on Personal Health Records and serving as the CMS liaison with several industry organizations, including WEDI and HITSP. He brings a wealth of experience and information regarding the use of standards and technology in the health care industry.

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