2019 Medicare Physician Fee Schedule (MPFS) Final Rule Released

On November 1st, CMS released the CY 2019 MPFS Final Rule, which will be published in the Federal Register on November 23, 2018.  CMS also released fact sheets on the physician payment provisions and the Quality Payment Program provisions.

2019 MPFS Conversion Factor 
The CY 2019 MPFS conversion factor is 36.04, which reflects the budget neutrality adjustment and the 0.25% adjustment factor update specified by the Bipartisan Budget Act of 2018.

Physician Payment Proposals

Evaluation and Management (E/M) Documentation and Payment

Following advocacy from ASCRS and the entire medical community in opposition to its proposals related to E/M documentation and payment in the proposed rule, CMS made substantial changes in the final rule for CY 2019. CMS finalized modified proposals that will reduce the burden of documenting E/M services in 2019, but delayed until CY 2021 several other provisions, including flawed payment proposals for E/M services. CMS is not finalizing the ASCRS- and medical community-opposed proposal to apply a multiple procedure reduction and reduce by 50% the lesser code when billed in conjunction with an E/M service. In addition, CMS is not finalizing its flawed proposed practice expense methodology for E/M visits.

For CY 2019, CMS is finalizing the following:

  • Eliminating the requirement to document the medical necessity of a home visit in lieu of an office visit;
  • For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so;
  • Clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter information in the medical record on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information; and
  • Removal of 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 for E/M visits furnished by teaching physicians.  

For CY 2021, CMS is finalizing the following provisions related to E/M:

  • ASCRS- and medical community-opposed collapse of E/M levels 2 through 4 for established and new patients, while maintaining the payment rate for E/M office/outpatient visit level 5, to better account for the care and needs of complex patients;
  • Permitting practitioners to choose to document E/M office/outpatient level 2 through 5 visits using medical decision-making (MDM) or time instead of applying the current 1995 or 1997 E/M documentation guidelines, or alternatively, practitioners could continue using the current framework;
  • Allowing for flexibility in how visit levels are documented—specifically a choice to use the current framework, MDM, or time; 
  • When time is used to document, practitioners will document the medical necessity of the visit and that the billing practitioner personally spent the required amount of time face-to-face with the beneficiary;
  • Implementation of add-on codes that describe the additional resources inherent in visits for primary care and particular kinds of non-procedural specialized medical care, but not including ophthalmology; and
  • Adoption of a new “extended visit” add-on code for use only with E/M office/outpatient level 2 through 4 visits to account for the additional resources required when practitioners need to spend extended time with the patient.

CY 2019 PFS Estimated Impact on Total Ophthalmology Allowed Charges

CMS adopted updated direct practice expense (PE) input prices for supplies and equipment, which would result in an overall 1% decrease in total ophthalmology allowed charges.

Medicare Telehealth Services

For 2019, CMS is expanding coverage for certain telehealth services. CMS will reimburse for virtual visits, interpretation of patient-submitted photos, and prolonged preventive services.

WAC-Based Payment for Part B Drugs: Proposal to Alter Add-on Amount

CMS is lowering the add-on for wholesale acquisition cost (WAC)-based payments for new Part B drugs to 3% in place of the 6% add-on that is currently being used.

2019 Quality Payment Program (QPP)

This final rule includes provisions for the 2019 performance year of the QPP, which includes MIPS and Advanced Alternative Payment Models (A-APMs), and impacts 2021 payments. Several of the 2019 provisions, including a major overhaul of the Promoting Interoperability (formerly Advancing Care Information) category of MIPS, are a result of ASCRS advocacy as part of the AMA MIPS workgroup. In addition, this rule implements the ASCRS-supported MACRA statute technical corrections enacted earlier this year.

Key 2019 MIPS Provisions:

  • Overhauling the Promoting Interoperability category to support greater electronic health record interoperability and patient access. Streamlining the category to remove the base and performance score and focusing on four objectives.
  • Modifying the low-volume threshold to add new criteria. In 2019, the low-volume threshold remains at $90,000 in allowed Part B charges or 200 patients, and adds 200 or fewer covered professional services.
  • Creating a MIPS opt-in for clinicians who exceed one or two, but not all three, low-volume criteria.
  • Continuing the small practice bonus, but moving it to the Quality category, rather than adding it to the MIPS final score. The bonus will be 6 points, rather than the proposed 3 points.
  • Implementing provisions of the MACRA technical corrections, including continuing transition flexibility, keeping the Cost category weight below 30%, and excluding Part B drugs from MIPS eligibility determinations and payment adjustments.

Performance Threshold:

The 2019 MIPS performance threshold is increased to 30 points, up from 15 points in 2018. The exceptional performance threshold is set at 75 points, rather than the proposed 80 points, up from 70 points in 2018. 

Performance Period: 

The performance period for the Quality and Cost categories remains at the full performance year and 90 days for the Promoting Interoperability and Improvement Activities categories.

Quality Category: 45% of 2019 MIPS Final Score 

For 2019, CMS will allow clinicians and groups to submit quality data through multiple submission mechanisms, such as claims and registry reporting. CMS will include the score from whichever mechanism is highest for each measure in the final category score. However, only small practices will be able to use claims reporting. CMS is maintaining the 60% data completeness threshold for measures in this category. Participants are still required to submit six quality measures, with at least one being an outcome measure, or high-priority if no outcome measure is available. Additional outcome measures and high-priority measures submitted will earn the same bonus points as previous years. Improvement scoring remains the same for 2019. 

CMS is removing the following ophthalmology quality measures:

  • #18, Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy, and
  • #140, Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement.

Cost Category: 15% of the 2019 MIPS Final Score

CMS will increase the weight of the Cost category to 15% but is keeping it below 30%, in accordance with the MACRA technical corrections. The two current measures, Medicare Spending per Beneficiary and Total per Capita Cost of Care, remain in the category. In addition, CMS will add eight episode-based cost measures, including one for cataract surgery, which was developed with input from ASCRS. Improvement in this category will not be scored until the 2024 payment year. 

Improvement Activities Category: 15% of the 2019 Final MIPS Score

CMS will continue its small practice accommodations in this category by awarding full credit to small practices that submit one high-weighted or two medium-weighted activities. CMS also finalized a new activity focused on promoting general eye exams.

Promoting Interoperability Category: 25% of the 2019 Final MIPS Score 

Following ASCRS advocacy, as part of the AMA MIPS Workgroup, CMS has made a major overhaul of this category to streamline and simplify the scoring. CMS has eliminated the base and performance scores and replaced it with a new methodology, but maintains the "all-or-nothing" scoring. CMS will use performance-based scoring at the individual measure level. Each measure would be scored based on the performance on the measure on the submission of a numerator and a denominator, or yes or no. The scores for each individual measure would be added together to calculate the score of up to 100 possible points. CMS will require 2015 certified EHR technology only for 2019.

Accountable Care Organizations (ACOs)

CMS is also finalizing some provisions of the Medicare Shared Savings ACO proposed rule that was released in August 2018 to allow ACOs whose participation agreements expire on December 31, 2018, to extend their agreements through June 2019.

Additional information will be detailed in upcoming editions of Washington Watch Weekly. For questions, please contact Allison Madson, manager of regulatory affairs, at 703-591-2220 or amadson@ascrs.org.