CMS Releases Proposed 2019 Medicare Physician Fee Schedule Rule

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  • July 13, 2018

On Thursday, July 12, CMS released the 2019 Proposed Physician Fee Schedule Rule. Below are a few of the proposed changes of interest to oncologists.

Streamlining Evaluation and Management (E/M) Payment and Reducing Clinician Burden
In the Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019 Fact Sheet, CMS states they are proposing to streamline E/M payment through their proposals:
• To allow practitioners to choose to document office/outpatient E/M visits using medical decision-making or time instead of applying the current 1995 or 1997 E/M documentation guidelines, or alternatively practitioners could continue using the current framework;
• To expand current options by allowing practitioners to use time as the governing factor in selecting visit level and documenting the E/M visit, regardless of whether counseling or care coordination dominate the visit;
• To expand current options regarding the documentation of history and exam, to allow practitioners to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting information, provided they review and update the previous information; and
• To allow practitioners to simply review and verify certain information in the medical record that is entered by ancillary staff or the beneficiary, rather than re-entering it.
In making these proposals, CMS states their primary goal is to reduce administrative burden so practitioners can focus on the patient, and they are seeking comments on whether or not their E/M proposals would in fact support that goal.
CMS also proposes to establish a single blended payment rate for E/M level 2-5 visits that they say could result in a 1-2% pay reduction for providers who typically bill the higher E/M visit levels. CMS states that any payment reduction would be offset by the “dramatic reduction” in administrative burden, as they would only require documentation to support the medical necessity of the visit and to support a level 2 CPT visit code.
Under this proposal, the proposed 2019 payment rates for new patient visits would be $44 for Level 1 E/M visits, and $135 for Level 2-5 E/M visits, while established patients visits would be reimbursed at $24 for Level 1 E/M visits, and $93 services for Level 2-5 E/M visits.
However, another proposal would apply the Multiple Procedure Payment Reduction (MPPR) when E/M services are furnished in conjunction with other services. As proposed, the MPPR would reduce payment by 50% for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit, currently identified on the claim by an appended modifier -25.
CMS is also proposing a new add-on code for certain specialties, GCG0X – Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, or interventional pain management-centered care (list separately in addition to an evaluation and management visit).

Part B Drugs – WAC Pricing
CMS proposes to reduce the add-on for wholesale acquisition cost (WAC) based payments for Part B drugs from WAC + 6% to WAC + 3%.
Conversion Factor
With the budget neutrality adjustment to account for changes in RVUs, the proposed 2019 PFS conversion factor is $36.05, a slight increase above the 2018 PFS conversion factor of $35.99.

Future Oplinc newsletters will provide more in-depth review of the 2019 Proposed Physician Fee Schedule Rule, which includes proposed changes to the Medicare Quality Payment Program (QPP) and other Medicare Part B payment policies.