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Physician Fee Schedule Final Rule

Source: Emily Hill, PA, AAPM Coding Consultant
Date: November 20, 2018

On November 1, 2018, the Centers for Medicare and Medicaid Services (CMS) released the 2019 Physician Fee Schedule (PFS) and Quality Payment Program (QPP) final rule, which will be published in the Federal Register on November 23, 2018.

The 2019 PFS conversion factor is $36.0391. This is a slight decrease from the amount set forth in the July Proposed Rule. The conversion factor is multiplied by the total adjusted Relative Value Units (RVUs) to achieve a payment amount for the services included in the Medicare Physician Fee Schedule.

The final decision regarding the proposed changes to E/M payment levels and documentation requirements was of significant concern to the medical community. CMS had proposed new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits along with a decrease in documentation requirements. CMS will not implement the changes in payment amounts for E/M services in 2019. However, it indicates the proposed changes will be implemented in 2021. The Final Rule acknowledges the work of the AMA and specialty societies in reviewing the current E/M codes and indicates its plan to review any changes to codes or code structures prior to implementing a change in payment rates for E/M codes. Further, CMS did not apply the proposed payment reduction when E/M services and procedures are reported on the same day with the modifier 25. The full allowable amount for both the E/M service and the procedure will continue to be made.

CMS did retain its proposal to decrease documentation requirements for office E/M services beginning in 2019. However, the specific application of this change in documentation requirements has not been clarified. CMS has indicated it will release a list of FAQs that will include clarification of the acceptable documentation standards particularly as it relates to the history component of the E/M service. AAPM will monitor the CMS website and relay pertinent information as it becomes available. Providers can continue to use the current 1995 or 1997 Documentation Guidelines.

CMS is expanding access to medical care using telecommunications technology by finalizing coverage of new CMS-created HCPCS codes for brief, non-face-to-face appointments via communications technology (virtual check-ins) and evaluation of patient-submitted photos. A third code that includes both services was created for federally qualified health centers and rural health clinics. CMS finalized new CPT codes for chronic care remote physiologic monitoring, agreed to reimburse for inter-professional consultations and expanded coverage for telemedicine services.

AAPM is hosting a webinar that will further review these initiatives and the Quality Payment Program (QPP) changes, provide an update on the Physician Fee Schedule as it impacts Pain Medicine practices, and review CPT and ICD-10 changes for 2019. The webinar titled, Preparing for 2019: Update on Coding and CMS Policy Changes, will be held on December 13 from 12-1 pm CT - Register Now

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