Physicians and other providers who bill for services under the Physician Fee Schedule (PFS) will see a small increase in the conversion factor for 2019, up 7¢ from the 2018 conversion factor to $36.04. In a final rule on Medicare payment policies under the PFS, CMS finalized many of its proposals, while changing others. A notable change is that although the agency is moving forward on its proposal to streamline the payment policies for evaluation & management (E/M) visits, the largest proposed change—a single payment rate for visits coded at Levels 2 through 5—will not be implemented until 2021, rather than 2019, and the single payment rate will only be for Levels 2 through 4; Level 5 visits, for the most complicated E/M cases, will be maintained at current rates due to complex patient needs. The final rule also makes changes to the data requirements and scoring for providers participating in the Medicare Quality Payment Program (QPP) through the Merit-based Incentive Payment System (MIPS) and as Advanced Alternative Payment Models (Advanced APMs), and finalizes some changes to the Medicare Shared Savings Program (MSSP) for accountable care organizations (ACOs) (Final rule, 83 FR 59836, November 24, 2018).
Rule overview. The rule finalizes PFS proposals (83 FR 35704) for payment policies, national uniform relative value units (RVUs), geographic adjustments, E/M visits, and the QPP (see CMS proposes single payment rate for Levels 2-5 E/M visits, July 27, 2018). All major final rules on Medicare payments, including this one, discuss service codes that may be added, revised, or potentially misvalued. To that end, the rule includes a lengthy discussion of standard clinical labor time minutes and reviewed Current Procedural Terminology® (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes, much based on comments received from public review, and which caused the agency to either change its plans, continue with its proposals, or promise to undertake further review of each issue. Like many other recent regulatory actions, it includes some provisions for providers in extreme circumstances, such as those impacted by hurricanes and other natural disasters. It includes statutory requirements, including those created by the Bipartisan Budget Act of 2018 (P.L. 115-123) and the Affordable Care Act (ACA) (P.L. 111-148).
The document also includes an interim final rule to implement provisions of the SUPPORT for Patients and Communities Act (SUPPORT Act) (P.L. 115-271) relating to Medicare telehealth and permissible originating sites for the telehealth treatment of a substance use disorder or co-occurring mental health disorder (see Trump signs wide-reaching opioid bill, October 24, 2018). The interim final rule will be effective for telehealth services provided to an individual with a diagnosis of substance use disorder beginning July 1, 2019.
E/M visits. The final rule contains a number of provisions designed to relieve the administrative burdens related to E/M visits. These changes include not requiring the documentation of medical necessity for E/M visits that take place at home rather than in an office, and allowing practitioners to document only recent changes and other pertinent information in an established patient’s medical record rather than a full medical history, so long as the provider indicates that she or he reviewed the prior data.
Starting in 2021, E/M visit levels will have a reduced payment variation. Rather than five payment rates for five levels of visit, Medicare will reimburse Part B providers at only three payment levels. Levels 1 and 5 will remain at their current levels, while Levels 2 through 4 will be paid at an identical rate. The agency also will be adopting an "extended visit" add-on code for Level 2 through 4 visits that require spending extended time with the patient to account for the additional resources expended in that situation. The American Medical Association (AMA) thanked CMS for the delay to 2021 of these changes, and announced its plan to have a work group convened to make recommendations on this topic based on participants’ knowledge of code valuation and various physician specialties.
Telemedicine. As more providers and patients are realizing the benefits associated with telemedicine and other technology-based communication services, CMS finalized proposals for two new services: virtual check-in, and remove evaluation of recorded video or images submitted by an established patient. In addition, CMS is including an interim final rule for telehealth services used in treatment of substance use disorders, including opioid use disorder, as required by the SUPPORT Act. An individual’s home will now be a permissible originating site for substance use disorder telehealth services, and other geographic requirements for originating sites are also being removed. There is a 60-day comment period for the interim final rule, and CMS particularly is asking for comments from opioid treatment programs that provide services under Part B, including for additional conditions of participation that may be useful as the agency continues to implement this benefit category.
QPP. The final rule adjusts the data submission requirements and performance categories used in calculating MIPS scores, and other changes to the QPP program related to eligible provider types and criteria for the low-volume threshold, and streamlined requirements for Advanced APMs.
MSSP. The final rule addresses some of the more time-sensitive proposals to change the MSSP (83 FR 41786) for ACOs that the agency says are necessary to ensure continuity of participation (see ACO participants: You want to play, put some skin in the game, August 17, 2018). Some of the proposals made to change the MSSP, which was created under Sec. 3022 of the ACA, were finalized relating to extending expiring participation agreements for existing ACOs, and reducing the core quality measure set. It also changes beneficiary assignment definitions, and allows prospective ACO assignment for beneficiaries who voluntarily align to certain types of providers if the clinician is aligned with that ACO. Lastly, it addresses relief for ACOs and ACO clinicians impacted by extreme and uncontrollable circumstances.
Other provisions. In a Fact Sheet, CMS detailed many of the changes included in the final rule. These include revisions to the physician supervision requirements for diagnostic tests performed by a radiologist assistant, addressed payment rates for non-excepted off-campus provider-based hospital departments, and made some changes to the Clinical Laboratory and Ambulance Fee Schedules. CMS finalized a policy related to wholesale acquisition costs of Part B drugs, and solicited comments on creating a bundled episode of care for management and counseling treatment for substance use disorders. Certain therapy services are also impacted by the rule, in which the agency discontinued the functional status reporting requirements for outpatient therapy services furnished on or after January 1, 2019, and established two new modifiers for services furnished in whole or in part by a physical therapy assistant or an occupational therapy assistant.
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