Breaking Down The Proposed Rule: 2019 Physician Fee Schedule & Quality Payment Program

Earlier this month, CMS dropped more than a few jaws with the release of its proposed changes to the 2019 Medicare Physician Fee Schedule and the Quality Payment Program. The aim? According to CMS, to reduce administrative and documentation-based burdens for physicians and their billing processes.

The agency says that the proposed changes would save individual physicians whose patient volumes are 40% Medicare-based, approximately 51 hours per year. They also estimate the proposed Quality Payment Program changes would collectively save physicians around 29,305 hours and approximately $2.6 million in reduced administrative costs.

But not everyone is smiling just yet – a number of major implications, perhaps the proposed adjustments to E&M coding chief amongst them, are sparking unease from some physician groups and organizations. Below, Genesis breaks down the key proposed shifts that you need to know:

Proposed Adjustment: E&M Coding & Documentation

• A new, simplified matrix of single, blended payment rates for New and Established patients for office-based (outpatient) E/M Level 2-5 visits have been proposed.
  • A number of new codes would be created to provide add-on payments to office visits for specific specialties ($9) and primary care physicians ($5).

                  Source: Aledade, Inc.

• When physicians report an E/M service and a procedure on the same date, CMS proposes to implement a 50% multiple procedure payment reduction to the lower paid of the two services.

Proposed Adjustment: Virtual Care & Telehealth Reimbursement

• Proposed expansions include payment for virtual check-ins and evaluation of patient-submitted photos or recorded video and Medicare-covered telehealth services for prolonged preventative care. Administrator Seema Verma said, “CMS is committed to modernizing the Medicare program by leveraging technologies, such as audio/video applications or patient-facing health portals, that will help beneficiaries access high-quality services in a convenient manner.”
• For RHCs/FQHCs: CMS is proposing payment 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 Adjustment: Part B Drug Reimbursement

• A significant reduction is proposed in the amount Medicare pays physicians for new prescription drugs.
  • Instead of calculating reimbursement by adding 6% to the wholesale acquisition cost (WAC) for drugs and biologics, CMS would pay physicians WAC plus 3% effective January 1.
    • This would not affect payments that are required by law to be calculated at the volume-weighted average sales price plus 6%.

Proposed Adjustment: Quality Payment Program – MIPS

• Expanding the definition of MIPS-eligible clinicians to include:
  • Physical and occupational therapists, clinical social workers and clinical psychologists
• Proposed 2019 performance year weights:
  • Quality: 45%
  • Cost: 15%
  • Promoting Interoperability (formerly Advancing Care Information): 25%
  • Improvement Activities: 15%
• Adjusting the low-volume threshold definition to include three components:
  • 200 or fewer beneficiaries
  • Equal to or less than $90,000 in Part B charges
  • 200 or fewer covered professional services (new)
    • Allowing physicians who meet one or two of the three components for low-volume designation to participate in MIPS by choice
• Continuing the small practice bonus but including it in the clinician’s Quality performance score,  instead of as a standalone bonus
• The proposed removal of 34 low-value/low-priority measures and an addition of 10 new measures
• Requiring the use of 2015-edition certified EHR technology

Other Important Things to Know

• Focus on the Opioid Epidemic
  • CMS is proposing to define opioid-related measures in the MIPS program as a “high priority.,” making clinicians who report high-priority metrics eligible for additional scoring in some circumstances. The agency hasn’t yet decided the specific metric, and is asking for comment on what measures to adopt.
  • CMS is also seeking to incentivize prescription drug monitoring program (PDMP) queries and their integration into EHRs. The e-prescribing section of the scoring formula would include a bonus for querying a relevant PDMP through an EHR.

Public comments on the proposed physician fee schedule are being accepted by CMS through September 10. Learn more about our RCM services.