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A Review of the CMS 2019 Physician Fee Schedule and Quality Payment Program Final Rule

The release of the Centers for Medicare and Medicaid Services' 2019 Physician Fee Schedule and Quality Payment Program final rule offered dramatic improvements for clinicians and patients. CMS is expanding the list of Medicare-covered telehealth services while also focusing on finalizing an overhaul of EHR requirements to promote interoperability. According to a CMS fact sheetCMS finalized several items designed to reduce the regulatory burden on physicians, effective January 1, 2019.  However, the controversial streamlined payment rates will be postponed to 2021 after an overwhelming amount of concern was expressed from the medical community.

E/M Changes Effective January 1, 2019

CMS will maintain separate payments for each distinct E/M code in 2019 and 2020 and practices will continue to use the current 1995 and 1997 documentation guidelines.

Some of the changes that will take effect on January 1 include:

  • Simplify the documentation of history and exam for established patients such that when relevant information is already contained in the medical record, clinicians can focus their documentation on what has changed since the last visit rather than having to re-document information.
  • Clarify that for both new and established E/M office visits, a Chief Complaint or other historical information already entered into the record by ancillary staff or by patients themselves may simply be reviewed and verified rather than re-entered.
  • Eliminate the requirement for documenting the medical necessity of furnishing visits in the patient’s home versus in an office.
  • Remove potentially duplicative requirements for certain notations in medical records that may have previously been documented by residents or other members of the medical team.

 

E/M Changes Intended for 2021

Coding requirements for physician services known as “evaluation and management” (E&M) visits have not been updated in 20 years. However, the controversial streamlined payment rates will be postponed to 2021 after an overwhelming amount of concern was expressed from the medical community.

"Commenters largely objected to our proposal to eliminate payment differences for office/outpatient E/M visit levels 2 through 5 based on the level of visit complexity," CMS states in the final rule. "A delayed implementation date for our documentation proposals would also allow the AMA time to develop changes to the CPT coding definitions and guidance prior to our implementation, such as changes to MDM [medical decision-making] or code definitions that we could then consider for adoption," CMS states. "It would also allow other payers time to react and potentially adjust their policies."

Those changes intended to take place in 2021 include:

  • Implement a single payment rate for visits currently reported as levels two, three, and four. These represent a majority of office/outpatient visits with clinicians. This means that for the majority of visits, the required documentation related to payment will be limited to what is required for a level two visit.
  • Retain a separate payment rate for the most complex patients – those currently reported through use of the level five codes. Also, CMS will retain the current separate code for level one visits, which are predominantly used for visits with clinical support staff.
  • Introduce coding that adjusts rates upward to account for additional resource costs inherent and routine in furnishing certain types of non-procedural care. These codes would only be reportable with level two through four visits, and their use generally would not impose new per-visit documentation requirements.
  • Introduce coding that adjusts rates upward for use with level two through four visits to account for the additional resource requirements when practitioners need to spend extended time with a patient.
  • Allow for flexibility in how level two through five visits are documented – specifically introducing a choice to use the current framework, medical decision-making, or time.

 

Year 3 of the Quality Payment Program Updates

Final policies for Year 3 of the Quality Payment Program will advance CMS’s Meaningful Measures initiative while reducing clinician burden, ensuring a focus on outcomes, and promoting interoperability.

“Today’s rule finalizes dramatic improvements for clinicians and patients and reflects extensive input from the medical community,” said CMS Administrator Seema Verma. “Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors. Today’s rule offers immediate relief from onerous requirements that contribute to burnout in the medical profession and detract from patient care. It also delays even more significant changes to give clinicians the time they need for implementation and provides time for us to continue to work with the medical community on this effort.”

Here is a quick overview of some of the Year 3 QPP updates:

  • The definition of a Merit-based Incentive Payment System (MIPS)-eligible clinician is expanded to include new clinician types, including physical therapists, occupational therapists, speech-language pathologists, audiologists, clinical psychologists, and registered dietitians or nutrition professionals.
  • Clinicians are excluded from MIPS if they have $90,000 or less in Part B allowed charges for covered professional services or they provide care for 200 or fewer Part B-enrolled beneficiaries.
  • For the third year, CMS also finalized a third low-volume threshold. Clinicians who furnish 200 or less covered professional services paid under the PFS are also excluded from MIPS.
  • Clinicians can choose to participate in MIPS in 2019 even if they are excluded from the program based on the low-volume threshold.
  • CMS finalized facility-based Quality and Cost performance measures for certain eligible clinicians. The new Quality Payment Program feature will allow MIPS eligible clinicians who furnish 75 percent or more of their covered professional services in inpatient hospital, on-campus outpatient hospital, or an emergency department to use facility-based scoring.
  • CMS increased the MIPS performance threshold to 30 points, up from the 15-point threshold in the second year of the Quality Payment Program. The exceptional performance threshold will also increase from 70 points to 75 points in 2019.
  • Quality is 45% of your score in 2019, Cost 15%, Promoting Interoperability (the former Advancing Care Information) 25% and Improvement Activities 15%. 

[Also: The Beginner's Guide to the Merit-based Incentive Payment System]

For a complete list of Quality Payment Program updates and E/M changes, please view the resources included below:

  • View the CY 2019 Physician Fee Schedule and Quality Payment Program final rule
  • View the fact sheet on the CY 2019 Physician Fee Schedule final rule
  • View the fact sheet on the CY 2019 Quality Payment Program final rule

 

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