2019 Physician Fee Schedule Proposed Rule Summary

2019 Physician Fee Schedule Proposed Rule Summary

Eli Fleet, MBA

Over the last year, the Centers for Medicare and Medicaid Services (CMS) has looked for various ways to reduce the burden of paperwork on clinicians who participate in its various programs so they can spend more time with their patients.

On July 12, CMS released their proposed changes to the Physician Fee Schedule (PFS) which include their proposed update to the Quality Payment Program (QPP) in the Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements Proposed Rule.

This is the first year that CMS has combined their annual PFS update with QPP, in its third year, in one proposed rule. They will continue to propose this combination going forward. With the proposal, CMS hopes to modernize Medicare payment policies to promote access to virtual care, saving Medicare beneficiaries time and money while improving their access to high-quality services no matter where they live.

Proposed PFS Key Changes

CMS has received extensive feedback which has highlighted a need to streamline the documentation requirements for physician services known as “evaluation and management” (E&M) visits, along with a need to support great access to care using telecommunications technology, something HIMSS has been proposing to CMS for the last couple of years. In allowing the electronic health records (EHRs) to be powerful tools to support efficient care, CMS hopes to give physicians more time to spend with their patients, especially those with complex needs, rather than on paperwork. The proposal looks to do this by:

  • Simplifying, streamlining and offering flexibility in documentation requirements for Evaluation and Management office visits – which CMS notes makes up about 20 percent of allowed charges under the PFS and consumes much of clinicians’ time.
  • Reducing unnecessary physician supervision of radiologist assistants for diagnostic tests.
  • Removing burdensome and overly complex functional status reporting requirements for outpatient therapy.

These proposed changes to the PFS will reinforce CMS’s Patients Over Paperwork initiative which focuses on reducing administrative burden while improving care coordination, health outcomes and patients’ ability to make decisions about their own care.

Changes to Virtual Care

The proposed PFS would support access to care using telecommunications technology in a number of ways. It would pay clinicians for virtual check-ins, which are described as brief non-face-to-face appointments via a communications technology, paying clinician for evaluation of patient-submitted photos, and expanding Medicare covered telehealth services to include prolonged preventive services.

Historically CMS has bundled "routine non-face-to-face communication" into the payment for the in-person visit, but in cases where a video or audio check-in doesn't lead to an office visit, there would be no office visit to bundle that payment to. The new payment system would also allow physicians to be paid for consultations with patients with whom they don't have a prior relationship. For instance, a patient could share videos or photos of a skin condition with a dermatologist to figure out if they need an in-person visit. In looking for ways to provide care of underserved communities, CMS is proposing payment for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for communication technology-based services and remote evaluation services that are furnished by an RHC or FQHC practitioner when there is no associated billable visit.

Proposed Calendar Year 2019 Quality Payment Program Key Changes

Within in the QPP part of the proposal, CMS would like to make changes to quality reporting requirements to focus on measures that most significantly impact health outcomes. The proposed changes would encourage information sharing among healthcare providers electronically, so patients can see various medical professionals based on their needs and expect that their updated medical records will follow them through the healthcare system.

This proposal also makes important changes to the Merit-based Incentive Payment System (MIPS) Promoting Interoperability performance category (formally known as Advancing Care Information) to support greater electronic health record (EHR) interoperability and patient access to their health information, as well as to align this clinician program with the proposed new Promoting Interoperability program for hospitals.

CMS proposes to expand the definition of MIPS eligible clinicians to include new clinician types (physical therapists, occupational therapists, clinical social workers and clinical psychologists). CMS is looking to add a third element (Number of Covered Professional Services) to the low-volume threshold determination and is providing an opt-in policy that offers eligible clinicians who meet or exceed one or two, but not all, elements of the low-volume threshold the ability to participate in MIPS. CMS is looking to move clinicians to a smaller set of Objectives and Measures with scoring based on performance for the Promoting Interoperability performance category.

For those smaller practices under MIPS, CMS is continuing the small practice bonus, but including it in the Quality performance category score of clinicians instead of as a standalone bonus.

CMS is looking to streamline the definition of a MIPS comparable measure in both the Advanced Alternative Payment Models (APMs) criteria and Other Payer Advanced APM criteria to reduce confusion and burden amongst payers and eligible clinicians submitting payment arrangement information to CMS. The proposal looks to update the MIPS APM measure sets that apply for purposes of the APM scoring standard. CMS is also looking to update the Advanced APM Certified EHR Technology (CEHRT) threshold so that an Advanced APM must require that at least 75 percent of eligible clinicians in each APM Entity use CEHRT.

Fighting the Opioid Crisis

In order to help fight the opioid crisis in the United States, CMS is proposing to tweak its MIPS formula to give credit to opioid-related technology in two ways. CMS looks to define opioids measures as a "high priority." Doctors who report high-priority metrics can get additional scoring in some circumstances. The agency hasn't yet decided the exact opioids-related metrics, and is asking for comment on what measures it should adopt. The second proposal CMS is suggesting on this topic is to incentivize prescription drug monitoring program (PDMP) queries and integration of PDMPs into EHRs. The e-prescribing section of the scoring formula would include a bonus section for querying a relevant PDMP through an EHR, reflecting the importance of integrating EHRs and PDMPs.

HIMSS will continue to provide updates and additional resources on this proposal ahead of the close of the comment period on September 10, as well as information once the rule is finalized in the fall of 2018. HIMSS will be commenting on the Proposed Rule and will do outreach to incorporate membership input in our comment letter.

CMS created a fact sheet on the 2019 Physician Fee Schedule piece of the proposed rule as well as a separate fact sheet on the 2019 Quality Payment Program piece of proposed rule.

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