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Updating the Way to Pay


CMS Proposes Major Changes to 2019 Physician Fee Schedule, QPP

Last month, the Centers for Medicare and Medicaid Services issued the proposed rule for the 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP). Billing the changes as 'historic' in an effort to 'modernize Medicare and restore the doctor-patient relationship,' the proposed rule looks toward administrative simplification to streamline paperwork when billing Medicare and to increase reimbursement options for telehealth services.

Seema Verma

In releasing the information, CMS officials also said the proposed rule would allow clinicians to document clinically meaningful information into the electronic health record (EHR) instead of information pertaining only to billing purposes. CMS Administrator Seema Verma said the proposed changes to the PFS and QPP underscores CMS' pledge to put patients over paperwork.

"Physicians tell us they continue to struggle with excessive regulatory requirements and unnecessary paperwork that steal time from patient care," stated Verma. "The proposed changes to the Physician Fee Schedule and Quality Payment Program address those problems head-on by streamlining documentation requirements to focus on patient care and by modernizing payment policies so seniors and others covered by Medicare can take advantage of the latest technologies to get the quality care they need."

The proposed rule includes a number of key changes to the PFS and QPP, in addition to rolling out a new demonstration project and requesting information regarding improved price transparency. Some of the major elements include:

Pricing Updates: The proposed 2019 PFS conversion factor is $36.05, which is a slight increase over the 2018 conversion factor. CMS worked with a contractor to conduct an in-depth market research study to update the direct practice expense inputs for supply and equipment pricing, which haven't been systematically updated for nearly 15 years. The contractor recommended pricing updates for about 1,300 supplies and 750 equipment items.

Streamlining Evaluation & Management (E&M) Payment and Reducing Documentation Burden: Having heard from stakeholders that the current documentation requirements for E&M codes has caused undue burden and created unintended consequences, the proposed PFS calls for simplifying requirements and offering more flexibility in documentation for E&M office visits, which CMS said makes up about 20 percent of allowed charges under the PFS. One provision looks to expand current options by allowing time spent or clinical decision-making to be a governing factor in selecting a visit level and documenting the E&M office visit, but providers could alternately continue using the current framework. Another part of the proposal would expand current history and exam documentation to allow providers to focus the documentation on what has changed (or pertinent info that has not changed) since the last visit rather than re-documenting everything as long as providers review and update the previous information.

Furthermore, the rule calls for reducing physician supervision of radiologist assistants for diagnostic tests and removing functional status reporting requirements for outpatient therapy. CMS has also proposed two new therapy modifiers for services furnished by or in part by a physical therapy assistant or an occupational therapy assistant. The new therapy modifiers for services provided by PTAs and OTAs wouldn't go into effect on claims until Jan. 1, 2020.

Additionally, CMS is also seeking comment on creating a bundled episode of care for the management and counseling treatment for substance use disorders. Specifically, the federal agency is asking for comment on methods to identify non-opioid alternatives for pain treatment and management and to highlight barriers to deploying those alternatives, including barriers related to reimbursement.

Virtual Care: "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," said Verma. The proposed rule supports telehealth efforts including paying clinicians for 'virtual check-ins' via telephone or other telecommunications device to decide whether an in-0ffice visit or other services are necessary, paying clinicians for the evaluation of patient-submitted photos, and expanding Medicare-covered telehealth services through new CPT codes for chronic care remote physiologic monitoring, interprofessional internet consultation, and prolonged preventive services.

Drug Costs: Proposed changes would impact payment under Medicare part B with CMS proposing a change in the payment amount for new drugs under Part B to "more closely match the actual cost of the drug." The change would be effective Jan. 2, 2019, and is anticipated to reduce the out-of-pocket cost for seniors.

Off-Campus Hospital Outpatient Services: The 2019 proposed rule continues a policy unpopular with hospitals and health systems that pays 40 percent of the outpatient rate for services provided in off-campus facilities that were built after Nov. 2, 2015.

While applauding CMS for a number of elements in the 2019 proposed rule, the American Hospital Association continues to be frustrated by the off-campus rule. As part of a larger statement on the PFS, AHA Executive Vice President Tom Nickels said, "We remain disappointed that CMS continues its short-sighted policies on the relocation of existing off-campus hospital outpatient departments. These "site-neutral" policies ignore the need for hospitals to modernize existing facilities so that they can provide the most up-to-date, high-quality services to their patients and communities. We also continue to urge CMS to improve its payment methodology to better account for the fact that the outpatient payment system includes many more services in its payment rates than the PFS."

QPP Changes: In an effort to reduce clinical burden, focus on outcomes and foster interoperability of EHRs, the proposed rule looks to remove 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," according to information released by CMS. Additionally, the federal agency is looking to overhaul the MIPS "Promoting Interoperability" performance category to support greater EHR interoperability and patient access to align the performance category with a similar interoperability program for hospitals.

MAQI Demonstration Project: Another proposal is to offer waivers of MIPS requirements as part of testing the Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) demonstration project. The demonstration waivers would be open to clinicians who participate sufficiently in Medicare Advantage arrangements similar to Advanced APMS but who are currently still bound to MIPS reporting requirements.

Request for Info on Price Transparency: CMS is also seeking comment to see if providers and suppliers can and/or should be required to tell patients about charge and payment information. The agency is also seeking information on the data elements that would be most useful to consumers to promote price comparisons when shopping for healthcare services.

Comments: All comments are due by Sept. 10, 2018.


CY 2019 Proposed Rules for Physician Fee Schedule & Quality Payment Program

PFS Fact Sheet

QPP Fact Sheet

MAQI Demonstration Project Information

Patients over Paperwork Initiative


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2019 Proposed Physician Fee Schedule, Administrative Simplification, Centers for Medicare and Medicaid Services, CMS, Evaluation & Management, MIPS, Patients Before Paperwork, PFS, QPP, Quality Payment Program, Telehealth, Tom Nickels
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