CMS Issues Final 2019 Payment Rules

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:

• The use of HCPCS G-codes and modifiers to report the required AUC information on Medicare claims for both the technical and professional components.
• Allowing delegation of AUC consultation with a qualified CDSM to clinical staff working under the direction of the ordering professional.
• Adding Independent Diagnostic Testing Facilities to the list of applicable settings under the mandate.
• Revising the significant hardship criteria to include insufficient internet access, electronic health record (EHR) or CDSM vendor issues, or extreme and uncontrollable circumstances

MPFS Policies effective January 1, 2019

Documentation Requirements

• CMS finalized several policies that will allow greater flexibility in how physicians choose to document patient encounters. For calendar years 2019 and 2020, physicians should continue to use either the 1995 or 1997 E/M documentation guidelines to document E/M office/outpatient visits for Medicare beneficiaries.
• CMS is also finalizing the following policies for 2019 and beyond:
• Elimination of the requirement to document medical necessity of a home visit in lieu of an office visit.
• For established patients’ office visits or outpatient visits, when the relevant information is already in the medical record, physicians may choose to focus additional documentation on changes since the last visits or on key items that have not changed since the last visit. Physicians do not need to re-record the defined list of required elements if there is evidence that the physician appropriately reviewed the previous information and updated as needed. Physicians should still review prior data, update as needed and indicate in the medical record that they have done so.
• For E/M office/outpatient visits for new and established patients, CMS is clarifying that physicians do not need to re-enter in the medical record information on the patients chief medical complaint and history if that information has already been put in the medical record by ancillary staff. The physician need only record that they reviewed and verified the information.
• Clarification of requirement for medical documentation performed by residents and other members of the medical team for E/M services provided by teaching physicians.

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.

SNMMI has prepared a detailed payment chart for the updated HOPPS rates which can be accessed here.