Summary of 2019 Physician Fee Schedule from HIMSS

Summary of 2019 Physician Fee Schedule from HIMSS


Over the last year, the Centers for Medicare and Medicaid Services (CMS) has continued to look for ways to address provider burden and deliver clinicians relief from documentation requirements tied to dated billing practices. On November 1 2018, CMS released its final changes to the Physician Fee Schedule (PFS) which include updates 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; Quality Payment Program; Medicaid Promoting Interoperability Program Final Rule.

This is the first year that CMS has combined its annual PFS update with QPP — which is in its third year — in one final regulation and CMS will continue to combine these two rule moving forward.

In the 2019 Final Rule, CMS finalized several health IT-related provisions, including measures to pay separately for two newly defined physicians’ services furnished using communication technology: brief virtual check ins between clinicians and Medicare beneficiaries; and remote evaluation of recorded video and/or images submitted to a clinician by an established patient. CMS is also promulgating final policies for Year 3 of QPP that advance CMS’s Meaningful Measures initiative and seek to reduce clinician burden, while focusing on patient outcomes and promoting interoperability between clinicians and beneficiaries.

Included below is more information about the provisions in the final rule.

E/M Documentation Coding Changes

CMS made significant changes to its evaluation and management (E/M) documentation requirements to help address clinician burden issues. The agency is changing the parameters around when a clinician has to document information in a patient’s electronic health record (EHR). CMS is eliminating the following documentation requirements:

  • For established patient visits, when relevant information is already contained in an EHR, clinicians can focus their documentation on what has changed since the last visit, or on relevant items that have not changed, and do not need to re-record the defined list of required elements, as long as they document that they reviewed the prior information and updated it as needed.
  • For new and established patients, clinicians do not need to re-enter information in EHRs on a patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary—clinicians just need to indicate that they have reviewed and verified this information.
  • Teaching physicians do not need to re-document information entered into an EHR by a medical resident or other members of the medical team.
  • Clinicians do not need to document the medical necessity of a home visit in place of an office visit.

CMS also delayed implementation of the blending of the E/M-based payment rates until 2021. For 2019 and 2020, CMS will continue the current coding and payment structure for E/M visits.

Changes to Virtual Care

The final PFS supports access to care using telecommunications technology in a number of ways. It pays clinicians for virtual check ins, which the rule describes as brief, non-face-to-face appointments through a communications technology, as well as pays clinicians for evaluation of patient-submitted photos, and expands 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 with which to bundle that payment.

Moreover, the new payment system will allow physicians to be paid for consultations with patients with whom they don't have a prior relationship. For example, a patient could share videos or photos of a skin condition with a dermatologist to figure out if an in-person visit is required. In addition, to help expand care to underserved communities, CMS finalized 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.

Fighting the Opioid Crisis

Through an interim final rule with comment period, CMS is implementing a provision from the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act that removes the originating site geographic requirements and adds the home of an individual as a permissible originating site for telehealth services. This change applies if furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019.

In addition, the SUPPORT for Patients and Communities Act establishes a new Medicare benefit category for opioid use disorder treatment services furnished by opioid treatment programs (OTP) under Medicare Part B, beginning on or after January 1, 2020.

Quality Payment Program Changes for 2019

Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), all eligible clinicians (ECs) who receive over a minimum threshold of Medicare Part B reimbursement must participate in an approved Advanced Alternative Payment Model (AAPM) or the Merit-Based Incentive Payment System (MIPS). ECs who do not participate in either option will receive a negative payment adjustment to their Medicare reimbursement.

In 2019, ECs (which will include a physician assistants, nurse practitioners and clinical nurse specialists in 2019) who charge more than or equal to $90,000 or provides care for 200 or fewer Part B–enrolled Medicare beneficiaries and are not part of an approved AAPM must participate in MIPS. Physical therapists, occupational therapists, qualified speech-language pathologists, qualified audiologists, clinical psychologists, registered dieticians, or nutrition professionals, and a group that includes such clinicians will be eligible for MIPS beginning in 2020.

CMS approved the following programs as approved AAPMs in the Final Rule:

  • Next Generation ACO Model
  • Comprehensive Primary Care Plus (CPC+) Model
  • Comprehensive ESRD Care (CEC) Model (Two-Sided Risk Arrangement)
  • Vermont All-Payer ACO Model (Vermont Medicare ACO Initiative)
  • Comprehensive Care for Joint Replacement Payment Model (CEHRT Track)
  • Oncology Care Model (Two-Sided Risk Arrangements)
  • Medicare ACO Track 1+ Model, Bundled Payments for Care Improvement Advanced
  • Maryland Total Cost of Care Model (Maryland Care Redesign Program; Maryland Primary Care Program)
  • Medicare Shared Savings Program Track 2
  • Medicare Shared Savings Program Track 3

Since the MIPS program was launched, clinicians who did not meet the minimum threshold requirements to be MIPS eligible were not allowed to participate in the MIPS program. Starting in 2019, CMS will allow clinicians who bill less than $90,000 or serve fewer than 200 Part B-enrolled patients to voluntarily participate in MIPS to gain the exposure to MIPS reporting without the fear of being penalized. MIPS will have four performance measurement categories in 2019 (with the weights for year 3 noted for each): Promoting Interoperability (25 percent); Quality (45 percent); Cost (15 percent); and Improvement Activities (15 percent).

The Performance Threshold is set at 30 points (with an additional threshold set at 75 points for exceptional performance). MIPS eligible clinicians receive a payment adjustment and/or an additional adjustment that is determined by comparing their final score to the performance threshold and the additional threshold. A final score that is at or above the performance threshold receives a neutral or positive payment adjustment, while a final score that is below the performance threshold receives a negative adjustment. The MACRA governing statute sets the maximum negative payment adjustment at -5 percent of Medicare Part B payments for items and covered professional services furnished by the MIPS eligible clinician.

MIPS Promoting Interoperability Performance Category

Formerly known as Advancing Care Information, this performance category’s name was changed to support greater EHR interoperability and patient access while aligning with the Medicare Promoting Interoperability Program requirements for hospitals.

For 2019, ECs must use 2015 Edition certified EHR technology (CEHRT) in Year 3 of the program. CMS is also instituting performance-based scoring at the individual measure level, where each measure will be scored based on a MIPS eligible clinician’s performance for that measure based on the submission of a numerator or denominator, or a “yes or no” submission (where applicable). For Promoting Interoperability, the scores for each of the individual measures will be added together to calculate the score of up to 100 possible points. If exclusions are claimed, the points for those measures will be reallocated to other measures.

There are four objectives in this performance category: e-Prescribing, Health Information Exchange; Provider to Patient Exchange; and Public Health and Clinical Data Exchange. Clinicians are required to report certain measures from each of the four objectives, unless an exclusion is warranted. CMS also finalized two new measures as optional with bonus points available for the e-Prescribing objective: Query of Prescription Drug Monitoring Program (PDMP); and Verify the existence of an Opioid Treatment Agreement.

MIPS Quality Performance Category

Individual or small practice ECs will have to report six clinical quality measures, one of which must be a high-priority measure (defined as an outcome measure, appropriate use, patient safety, efficiency, patient experience or care coordination quality measure) from the final set of CMS-approved clinical quality measures for a full calendar year in order to avoid a negative payment adjustment for 2019. The quality score will constitute 45 percent of the overall MIPS score for each EC.

Utilizing the Meaningful Measures framework CMS has finalized a list of quality measures which:

  • Safeguard public health
  • Are meaningful to patients
  • Are outcome-based where possible
  • Minimize administrative burden for providers
  • Reflect a significant opportunity for improved outcomes

From this list of more meaningful quality measures, individual ECs, small groups and specialists must report their six quality measures. Of the available measures, different measures can be captured and reported via electronic clinical quality measure (eCQM) reporting from CEHRT, registry-based quality measures, qualified clinical data registry measures (QCDR) and claims measures. For the first time, in 2019, ECs may select multiple reporting methodologies for each quality measure. CMS will also provide a scoring bonus for ECs that choose to report all six quality measures as eCQMs.

Individual, small group, and specialists reporting as individual ECs must capture their quality measures for the full calendar year (January 1, 2019-December 31, 2019) and report their six measures to CMS no later than March 31, 2020, through the prescribed reporting methodology for the selected measure. Scoring bonuses are provided for ECs which report on high-priority measures.

CMS will also provide bonuses for ECs who care for more complex patients. High-complexity patients will be defined as patients with high medical risk or with dual eligibility for Medicare and Medicaid. CMS will also calculate scoring bonuses based on the average Hierarchical Condition Category (HCC) risk score for each EC’s patient population. The agency hopes that the scoring bonus will offset the impact that medically complex patients will have on EC quality performance scores.

Large groups (groups of 25 or more ECs with the same tax identification number) have the option for each EC to report individually, or submit their quality measures via the CMS Web Interface tool as a group. Group reporting also requires ECs to capture clinical quality data for a full calendar year (January 1, 2019-December 31, 2019) and submitted to CMS no later than March 31, 2020.

Large groups must report on all the CMS quality measures found in the CMS Web Interface tool. Those measures (11 in total) also align with the clinical quality measures found as part of the Medicare Shared Savings Program (MSSP) Quality Reporting. MIPS ECs reporting as part of a group that also participates in MSSP will be allowed to report the same data to meet requirements for both programs.

MSSP Quality Reporting in 2019

CMS finalized proposals to redesign the participation options available to participants in MSSP. Options which did not include some form of down-side financial risk for participants have been eliminated, meaning that participating providers that do not meet minimum performance thresholds for a reporting period risk receiving significant negative payment adjustments starting in July 2019. The remaining MSSP pathways (Basic and Advanced) align closely with the current MSSP Track 3 performance criteria. CMS will address the specifics for the new pathways in a future final rulemaking.

As discussed, CMS finalized quality measures which align with the group reporting measures for MIPS participants. MSSP participants will be required to capture those clinical quality measures for a full calendar year, report the performance on those measures to CMS, and meet specified quality thresholds in order to meet the quality requirements for earning shared savings. The final rule reduced the number of quality measures which MSSP participants were required to report by eight measures.

Unlike MIPS participants, MSSP ECs must also submit Agency for Healthcare Resources and Quality (AHRQ) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses and claims data for CMS to measure patient and care giver satisfaction and care coordination performance.

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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