CMS RELEASES PHYSICIAN FEE SCHEDULE FINAL RULE FOR 2019

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  • November 21, 2018

On November 1, 2018, CMS released the CY 2019 Physician Fee Schedule (PFS) rule. In the final rule, CMS postpones most of the documentation and payment changes to evaluation and management (E/M) codes until calendar year (CY) 2021.

CY 2019 & 2020 – E/M documentation rules finalized for CY 2019 & 2020 will allow providers to continue to document based on 1995 or 1997 documentation guidelines. Changes to documentation for CY 2019 & CY 2020 include the following:

  • History and Exam – for established patients, providers are only required to focus on what has changed since the last visit or pertinent items that have not changed. Providers must still review prior data, update the information as necessary, and indicate in the medical record that they have done so.
  • Chief Complaint and History – for both new and established patients, practitioners may review and verify the chief complaint and history entered by ancillary staff or the beneficiary. The practitioner will not have to re-enter the information but must indicate in the medical record that they reviewed and verified this information.

CY 2021 – The proposed changes to E/M RVUs & Blended Payment Rates were postponed and have been finalized for CY
2021. These changes include:

  • A single set of RVUs and a single payment rate for E/M office-based and outpatient visit levels 2-4 for new and established patients (CPT codes 99202-99204 and 99212-99214)
  • Practitioners would bill the CPT code for whichever level of E/M service they furnished but they would be paid at the single rate for E/M levels 2-4.
  • For E/M levels 2-4, would only require documentation to support a level 2 E/M office/outpatient visit code for history, exam and/or medical-decision making.
  • Under the final rule, CMS maintains a separate payment rate for visit level 5 to better account for the care and needs of complex patients.

CY 2021 -Documentation changes finalized for CY 2021 include documentation flexibility for E/M office/outpatient levels 2-5 visits:

  • Use the current documentation framework – 1995 or 1997 E/M documentation guidelines, or
  • Medical-decision making, or
  • Time – must document medical necessity and that the billing practitioner personally spent the required amount of time face-to-face with the beneficiary.

CY 2021 – New add-on codes (billed in conjunction with an E/M code):

  • GCG0X Visit complexity inherent to evaluation and management associated with nonprocedural specialty care
    including endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, interventional pain management, cardiology, nephrology, infectious disease, psychiatry, and pulmonology. (Add-on code, list separately in addition to level 2 through 4
    office/outpatient evaluation and management visit, new or established) Approx. $14
  • GPRO1 (Extended time for evaluation and management service(s) in the office or other outpatient setting, when the visit requires direct patient contact of 34-69 total face-to-face minutes overall for an existing patient or 38-89 minutes for a new patient (List separately in addition to code for level 2 through 4 office or other outpatient Evaluation and Management service)). Approx. $67

CY 2019 – New Part B Drugs and Wholesale Acquisition Cost (WAC) add-on payment finalized for CY 2019 – CMS finalized their proposal to adjust the add-on payment for Part B Drugs paid through WAC methodology. New drugs coming to market are paid at WAC pricing during the 1st quarter as they have no established Average Sales Price (ASP). Currently new drugs paid under the WAC methodology are paid at WAC + 6%, CMS finalized their proposal to lower the WAC add-on to WAC + 3% effective January 1, 2019.

2019 Medicare Physician Fee Schedule Final Rule:
https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf

Watch for our detailed analysis of the 2019 Physician Fee Schedule (PFS) and Outpatient Prospective Payment System (OPPS) Final Rule in upcoming Oplinc Newsletters.