Heart of Health Policy | Highlights of Proposed Medicare PFS and QPP from CMS

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Each July the Centers for Medicare and Medicaid Services (CMS) releases its proposed Medicare Physician Fee Schedule (PFS) addressing Medicare payment and quality provisions for the coming year.

The new 2019 proposed PFS would result in most physicians seeing a less than 0.1 percent conversion factor payment increase on Jan. 1, 2019 – keeping in mind that estimates are based on cardiovascular practice in its entirety and can vary widely depending on the mix of services provided in a practice. CMS estimates that the physician rule will decrease payments to cardiologists by 1 percent from 2018 to 2019 due to changes in practice. Highlights from the proposed rule include:

Streamlining evaluation and management (E/M) documentation to reduce clinician burden by allowing use of time to serve as the governing factor for selecting 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.

Note: Look for more information on this proposed change at ACC.org/Advocacy and in next month’s Cardiology.

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.

Note: CMS projects the changes will have a minimal overall impact to cardiology charges. The ACC is working with its members and other societies to determine potential impacts.

Continuing implementation of the mandate 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.

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.

In addition to the changes outlined above, the proposed rule also includes updates to the Quality Payment Program (QPP) for the 2019 performance period. Reweighting the Merit-Based Incentive Payment System (MIPS) categories to 45 percent Quality, 25 percent Promoting Interoperability (formerly Advancing Care Information), 15 percent Cost and 15 percent Improvement Activities. Other highlights include:

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 to 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 electronic heath record technology.

ACC staff and Health Affairs Committee continue to review the rule and will submit written comments in the coming weeks. CMS will release a final rule in the fall.

Keywords: ACC Publications, Cardiology Magazine, Health Policy, Value-Based Purchasing, Centers for Medicare and Medicaid Services, U.S., Physicians, Primary Care, Motivation, Peripheral Arterial Disease, Decision Support Systems, Clinical, Myocardial Infarction, Myocardial Infarction, Area Under Curve, Outpatients, Medicare, Medicaid, Fee Schedules, Cardiac Output, Exercise Therapy, Medical Records, Monitoring, Physiologic, Documentation, Counterpulsation, Prospective Payment System, Lower Extremity, Pacemaker, Artificial, Percutaneous Coronary Intervention

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