CMS Releases Proposed 2019 Medicare Physician Fee Schedule

On July 12, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2019 Medicare Physician Fee Schedule (PFS) addressing Medicare payment and quality provisions for the coming year. Under the proposal, physicians will see a less than 0.1 percent conversion factor payment increase on Jan. 1, 2019. CMS estimates that the physician rule will decrease payments to cardiologists by 1 percent from 2018 to 2019 due to changes in practice. Estimates are based on cardiovascular practice in its entirety and can vary widely depending on the mix of services provided in a practice. The proposed rule also includes updates to the Quality Payment Program (QPP) for the 2019 performance period.

Proposed Changes for 2019 Medicare PFS:

  • Streamlining evaluation and management (E/M) documentation to reduce clinician burden by allowing use of time to serve as the governing factor for selective the level of an E/M visit; allowing clinicians to focus on relevant documentation changes rather than re-documenting redundant information; allowing the documentation of medical decision-making or time; and allowing clinicians to review and verify some medical record information entered by staff or the beneficiary instead of re-entering information. The ACC has advocated for the simplification of E/M documentation requirements as part of efforts to reduce administrative burden.
  • Implementing a single, blended payment rate for E/M levels two through five visits, paired with new add-on code (GCG0X) to capture the complexity of specialty E/M care, a new add-on code (GPC1X) to capture the complexity of ongoing care provided to an established patient by a primary care physician and adjustments to the practice expense formula for these services to account for differences in resource costs among certain types of E/M visits. CMS projects the changes will have a minimal overall impact to cardiology charges.
  • Continuing implementation of the requirement ordering that clinicians consult with appropriate use criteria (AUC) through a qualified clinical decision support mechanism (CDSM) for advanced imaging services starting Jan. 1, 2020. No further delay to the program's start date was proposed. Additional proposals include:
    • Using HCPCS G-codes and modifiers to report the required AUC information on Medicare claims forms.
    • Expanding the requirement to comply with the mandate to Independent Diagnostic Testing Facilities.
    • Revising the significant hardship criteria to include insufficient internet access, electronic health record (EHR) or CDSM vendor issues or extreme and uncontrollable circumstances.
  • Creating values for new codes describing leadless pacemaker services, subcutaneous quantitative cardiac rhythm monitor services (loop recorder), pulmonary wireless pressure sensor services and chronic care remote physiologic monitoring services, and updating values for external counterpulsation, coronary fractional flow reserve measurement, supervised exercise therapy for peripheral artery disease and cardiac output dilution studies.
  • Maintaining the payment rate for certain non-excepted off-campus provider-based departments paid under the PFS (Section 603) at 40 percent of the Hospital Outpatient Prospective Payment System rate.
  • Reducing the number of quality measures in the Medicare Shared Savings Program from 31 to 24 and applying a similar measure reduction in the Merit-Based Incentive Payment System (MIPS) measure set as part of the continued Meaningful Measures initiative.

Proposed Changes for 2019 QPP Performance Period:

  • Reweighting the MIPS categories to 45 percent Quality, 25 percent Promoting Interoperability (formerly Advancing Care Information), 15 percent Cost and 15 percent Improvement Activities.
  • Increasing the MIPS performance threshold for avoiding a penalty to 30 points and the exceptional performance threshold to 80 points.
  • Incorporating episode groups into the MIPS Cost score, including STEMI with PCI, elective outpatient PCI and revascularization for lower extremity chronic critical limb ischemia.
  • Maintaining the low-volume threshold for MIPS exemption at $90,000 or less in part B allowed charges or 200 or fewer Medicare beneficiaries; adding a third exclusion for clinicians providing 200 or fewer covered professional services under the PFS; and continuing the small practice bonus. Small practice bonus points will be added to the Quality category, not the overall MIPS score.
  • Allowing individuals and groups to submit MIPS data using multiple submission types per category.
  • Implementing facility-based MIPS scoring that would allow "facility-based clinicians" to use the Hospital Value-Based Purchasing Program performance for the MIPS Quality and Cost categories.
  • Maintaining the revenue-based nominal amount threshold for Advanced Alternative Payment Models (APMs) at 8 percent through performance year 2024.
  • Requiring at least 75 percent of eligible clinicians in an Advanced APM use certified EHR technology.

ACC staff are actively reviewing the proposed rule to identify additional topics of interest for members. The College will submit written comments in response to the proposal in the coming weeks. CMS will release a final rule in the fall.

Prior to the release of the final rule, experts will discuss the implications of these proposed changes, among other federal legislative and regulatory topics, at ACC's 2018 Legislative Conference Sept. 30 – Oct. 2 in Washington, DC. Register here.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Heart Failure, Mechanical Circulatory Support, Interventions and Vascular Medicine

Keywords: ACC Advocacy, Healthcare Common Procedure Coding System, Value-Based Purchasing, Centers for Medicare and Medicaid Services (U.S.), Decision Support Systems, Clinical, Physicians, Primary Care, Peripheral Arterial Disease, Outpatients, Medicare, Medicaid, Fee Schedules, Electronic Health Records, Counterpulsation, Prospective Payment System, Percutaneous Coronary Intervention, Quality Payment Program

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