November 2, 2018
Medicare Physician Fee Schedule
The Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2019 Medicare Physician Fee Schedule (MPFS) final rule on Thursday, November 1st. CMS finalized a CY 2019 conversion factor of $36.0391, which reflects the 0.25 percent update specified by the Medicare Access and CHIP Reauthorization Act and a budget neutrality adjustment of -0.14 percent. This is a slight increase from the current conversion factor.
The mandate requires that clinicians consult appropriate use criteria (AUC) through a qualified clinical decision support mechanism (CDSM) starting Jan. 1, 2020, when ordering advanced imaging services (i.e., SPECT/PET MPI, CT and MR).
Other finalized policies include:
MPFS Policies effective January 1, 2019
Documentation Requirements
CMS Recognizes New Technology
Interprofessional Internet Consultation (CPT codes 99451, 99452, 99446, 99447, 99448, and 99449)
In 2019, CMS has reevaluated past decisions not to pay for interprofessional internet consultations and established rates for existing CPT codes. CMS states, "in light of changes in medical practice and technology, we [CMS] proposed to change the procedure status for CPT codes 99446, 99447, 99448, and 99449 from B (bundled) to A (active). We {CMS] also proposed the RUC re-affirmed work RVUs of 0.35 for CPT code 99446, 0.70 for CPT code 99447, 1.05 for CPT code 99448, and 1.40 for CPT code 99449."
Additionally, new in 2019, CMS is establishing codes and rates for:
HCPCS code G2010 Remote pre-recorded services
G2010 Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with verbal follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment), 2019 rate $12.61 Non-facility
HCPCS Code G2012 Brief Communication Technology-based Service, e.g. Virtual Check-in
G2012 Brief communication- technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion, 2019 rate $14.78 Non-facility
Changes Finalized for 2021
E/M Office Visits – Combining E/M Levels 2-4 into a Single Payment Level
Starting in 2021, CMS has finalized policy that it will combine payment for level 2-4 E/M office and outpatient visit into a single payment - effectively moving from five levels for E/M office/outpatient visits to three levels. The level 5 E/M office/outpatient visit has been retained.
E/M Documentation and Level Selection Criteria
Also starting in 2021, physicians can choose to document E/M office/outpatient visits for levels 2 through 5 using, medical decision making, time, 1995 or 1997 framework. Further, CMS will apply the minimum documentation standard associated with a level 2 visit. Physicians can use medical decision making, time, 1995 or 1997 guidelines for choosing the appropriate level of an E/M services.
When physicians use time for documentation, they must document the medical necessity of the visit and that the billing physician personally spent the required amount of time face-to-face with the patient.
Policies Not Adopted
The final rule is also significant for policy proposals that CMS did not move forward with, including the Multiple Procedures Payment Reduction proposed rule. CMS had initially proposed new policy that – when an E/M service and additional procedure or procedures are offered on the same day – CMS would automatically reduce payment for the least expense service offered by 50 percent. If implemented, physicians would have been stuck with either absorbing significant payment reductions for services provided to Medicare beneficiaries or forcing patients to return for multiple office visits or to receive treatment or testing on different days. Neither option was in the best interest of patient care.
CMS, responded to strong physician opposition to the MPPR with E/M services proposed and did NOT finalize this policy.
SNMMI has prepared a detailed payment chart for the updated MPFS rates which can be accessed here.
Hospital Outpatient Prospective Payment System
On November 2, 2018, the Centers for Medicare and Medicaid Services published the calendar year (CY) 2019 Hospital Outpatient Prospective Payment System (HOPPS) final rule. The finalized changes are effective January 1, 2019. CMS finalized a 1.35 percent increase of the conversion factor. The new conversion factor is $79.490 for CY 2019. The reduced conversion factor for hospitals failing to meet the Hospital Outpatient Quality Reporting (OQR) Program requirements was finalized to $77.955.
No new changes were proposed to the APC structure for imaging codes. CMS will continue paying for drugs and therapeutic radiopharmaceuticals at ASP + 6% as set forth in the CY 2010 OPPS/ASC Final Rule. The threshold payment for therapeutic radiopharmaceuticals is $125 where CMS will package those that are priced less or equal to $125 into the APC payments and pay separately for those that meet or exceed this threshold amount.
Additionally, CMS will continue to pay off-campus sites that are more than 250 yards from the main campus and began providing services on or after November 2, 2015 at 40% of the HOPPS rate. CMS did not finalize the proposed policy that off-campus provider based departments (PBDs) excepted from Section 603 of the Bipartisan Budget Act of 2015 could continue to be paid at OPPS rates for items and services in each of 19 proposed “clinical families of services” if a PBD furnished and billed for a service in that clinical family of services prior to November 2, 2015. CMS plans to continue to monitor the expansion of services in these departments.
# |
APC |
CMS Group Title |
SI |
Payment Rate October 2018 F |
Payment Rate 2019 P |
Payment Rate 2019 F |
Percentage change |
1 |
5591 |
Level 1 Nuclear Medicine & Related Services |
S |
$349.44 |
$354.63 |
$353.49 |
1.1% |
2 |
5592 |
Level 2 Nuclear Medicine & Related Services |
S |
$453.08 |
$455.77 |
$455.52 |
0.5% |
3 |
5593 |
Level 3 Nuclear Medicine & Related Services |
S |
$1,202.68 |
$1,227.59 |
$1,229.38 |
2.2% |
4 |
5594 |
Level 4 Nuclear Medicine & Related Services |
S |
$1,377.22 |
$1,386.06 |
$1,375.54 |
-0.1% |
5 |
5661 |
Therapy Nuclear Medicine |
S |
$238.48 |
$234.88 |
$230.89 |
-3.3% |
SNMMI has prepared a detailed payment chart for the updated HOPPS rates which can be accessed here.