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CMS Releases Proposed Rule for 2019

Source: Emily Hill, PA, AAPM Coding Consultant
Date: July 23, 2018


On July 12, 2018, the Centers for Medicare and Medicaid Services (CMS) released the 2019 Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP) Proposed Rule. This is the first time that CMS has combined the two programs into a single proposed rule. CMS is requesting comments on the proposed rule by September 10, 2018, and a final rule is expected to be released in November.

The proposed conversion factor for 2019 is $36.0463. This reflects a statutory update of .25%, offset by a budget neutrality adjustment of -0.12 percent, resulting in a 0.13 percent update. 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 Proposed Rule also provides an update to the global surgical data collection intended to assess the accuracy of global surgical package valuation. The data collection was mandated as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and was initiated in July 2017. Groups of 10 or more practitioners in 9 nine states were required to use CPT code 99024 to report postoperative visits for selected procedures. Only 45% of practitioners that met the criteria for reporting participated. Of those "robust participators", only 16% of the 10-day global services and 87 % of 90-day global services had one or more matched visits reported. In the Proposed Rule, CMS is seeking comments on ways to increase participation in the data collection and also if visits are typically being performed in the 10-day global period.

Perhaps receiving the most attention, are coding and payment proposals for Evaluation and Management Services (E/M). CMS is proposing new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits. A series of add-on codes would be available for select specialties, primary care and for prolonged E/M services. In conjunction, they are proposing that codes be selected based on medical decision-making alone or face-to-face time with the patient rather than the current 1995 or 1997 Documentation Guidelines. Providers who choose to continue using the Documentation Guidelines would need to meet the minimum documentation standards for a level 2 E/M service. CMS is also proposing other documentation changes designed to reduce the documentation burden on physicians. CMS is seeking comments on other documentation systems and the relationship to Electronic Health Records as well as how documentation guidelines for the medical decision-making component might be changed. The proposed blended payment rate for established patient E/M services 2-5 is $92 and for new patient encounters levels 2-5 the rate is $134.

In addition to the changes in documentation and payment rates, CMS is also proposing a multiple service reduction of 50% for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnishes on the same day as a separately identifiable E/M visit.

The Proposed Rule also addresses the valuation of specific services as well as the processes for determining the practice expense and malpractice RVUs assigned to services. The AMA and specialty societies, including AAPM, are in the process of reviewing these and other proposals.

CMS has published several fact sheets on the rule including a fact sheet on the PFS proposals for 2019. The entire Rule can be accessed at: Revisions to Payment Policies under Physician Fee Schedule and Other Revisions to Part B for CY 2019; Medicare Shared Savings Program Requirements.

The proposed changes to the Quality Payment Program will be addressed in the next e-news.

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