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Proposed 2019 Fee Schedule is out – hang on to your seats…

CMS released the 12th of July the proposed changed for the physician fee schedule for 2019 (https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2018-Press-releases-items/2018-07-12.html). Here are some of the highlights

1)     Changes to EM system – Probably the biggest and the one that caught everyone’s eye was the “Streamlining E/M Payment and reducing clinician burden. Specifically, they state “Responding to stakeholder concerns, several provisions in the proposed CY 2019 Physician Fee Schedule would help to free EHRs to be powerful tools that would actually support efficient care while giving physicians more time to spend with their patients, especially those with complex needs, rather than on paperwork. Specifically, this proposal states:

CMS is proposing several coding and payment changes to reduce administrative burden and improve payment accuracy for E/M visits. We propose:

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.”

The proposal also has some interesting aspects such as having a ‘single blended payment rates for new and established patients for office/outpatient EM levels 2-5 visits with a series of ‘add-on’ codes to reflect resources involved in furnishing primary care and non-procedural specialty generally recognized services. They would also see about have the ‘standard’ documentation for levels 2-5 OR more of just medical decision-making to determine the levels 2-5 or using just time even without it being counseling. For time documentation they would still require the ‘medical necessity’ for the encounter, also the total amount of time spent face-to-face with the patient. They would still allow providers to add additional documentation for clinical, legal, operational or other purposes, however CMS would only require documentation to support the medical necessity of the visit, etc.

When it comes to EM services were minor procedures are also performed, CMS proposes “a multiple procedure payment adjustment that would apply.” Which appears to infer similar reductions that are currently applied for multiple surgical procedures performed during the same encounter/date.  They also want to develop a separate set of coding EM visits for podiatry services. They are also proposing a ‘new prolonged face-to-face EM code, as well as a technical modification to the practice expense methodology.’

CMS is also seeking public comment on ‘potentially eliminating a policy that prevents payment for same-day EM visits by multiple practitioners in the same specialty within a group practice.’ For EM visits furnished by teaching physicians they are proposing ‘to eliminate potentially duplicative requirements for notations in medical records that may have previously been included in the medical records by residents or other members of the medical team.’

Finally, CMS states: “We are soliciting public comment on the implementation timeframe of these proposals, as well as how we might update E/M visit coding and documentation in other care settings in future years. CMS believes these proposals would allow practitioners greater flexibility to exercise clinical judgment in documentation, so they can focus on what is clinically relevant and medically necessary for the beneficiary.”

2)   Discontinue Functional Status Reporting Requirements for Outpatient Therapy

3)     Outpatient PT and OT Services Furnished by Therapy Assistants – “The Bipartisan Budget Act of 2018 requires payment for services furnished in whole or in part by a therapy assistant at 85 percent of the applicable Part B payment amount for the service effective January 1, 2022. In order to implement this payment reduction, the law requires us to establish a new modifier by January 1, 2019 and we detail our plans to accomplish this in the proposed rule. We are proposing to establish two new therapy modifiers – one for PT Assistants (PTA) and another for OT Assistant (OTA) – when services are furnished in whole or in part by a PTA or OTA. These are to be used in conjunction with the three existing therapy modifiers that have been used since 1998 to track outpatient therapy services that were subject to the therapy caps. The new therapy modifiers for services furnished by PTAs and OTAs are not required on claims until January 1, 2020.

4)   Conversion Factor – Proposed $36.05 up from the 2018 value of $35.99

5)   Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging

6)     Patient’s over paperwork – CMS has also released a video https://www.cms.gov/About-CMS/story-page/patients-over-paperwork.html

Learn how we’re putting patients over paperwork and they list things like Implementing MACRA to lessen your burden & cost; Cutting documentation requirements; Making the medial review process clearer; Making it easier for people to get the treatment they need; Making meaningful measures; and lowering drug costs

7)     Increasing Telecommunications

8)     Removing MIPS process-based quality measures that clinicians have said are low-value or low-priority, in order to focus on meaningful measures that have a greater impact on health outcomes

9)     Overhauling the MIPS “Promoting Interoperability” performance category to support greater EHR interoperability and patient access to their health information

10)Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration

11)Price transparency: Request for information

Public comments on the proposed rules are due by September 10, 2018.

Please take the time to read through the sections, especially the changes to EM reporting and make your comments BEFORE the Sept 10th deadline. As I continue to read through the 1473 pages if I found other exciting things relating to Orthopedic issues, I will let you know, but the second link below will get you your own copy of those pages that you can also browse through.  For more information:

For a fact sheet on the CY 2019 Physician Fee Schedule proposed rule, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-12-2.html

To view the CY 2019 Physician Fee Schedule proposed rule, please visit: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf 

For a fact sheet on the CY 2019 Quality Payment Program proposed rule, please visit: https://www.cms.gov/Medicare/Quality-Payment-Program/Resource-Library/2019-QPP-proposed-rule-fact-sheet.pdf

To view the CY 2019 Quality Payment Program proposed rule, please visit: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf

For a fact sheet on the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheets-items/2018-07-12.html