2019 Medicare Physician Fee Schedule (MPFS) Proposed Rule Released

On Thursday, July 12th, CMS released the CY 2019 MPFS Proposed Rule, which will be published in the Federal Register on July 27, 2018, with a 60-day comment period. ASCRS will be submitting comments. CMS also released a fact sheet and press release on this proposed rule.

2019 MPFS Conversion Factor
The CY 2019 proposed MPFS conversion factor is $36.0463, which reflects the budget neutrality adjustment and the 0.25% update adjustment factor specified by the Bipartisan Budget Act of 2018.

Physician Payment Proposals

CY 2019 PFS Estimated Impact on Total Ophthalmology Allowed Charges

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

Streamlining Evaluation and Management (E/M) Payment and Reducing Clinician Burden

CMS is proposing a number of coding and payment changes to reduce administrative burden and improve payment accuracy for E/M visits, including:

  • 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;
  • 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;
  • Expanding 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
  • Allowing 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.

Medicare Telehealth Services

For 2019, CMS is proposing to expand coverage for certain telehealth services. CMS proposes to reimburse for virtual visits, interpretation of patient-submitted photos, and prolonged preventative services.

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

CMS is proposing to lower 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 proposed rule includes proposals 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 changes proposed, 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 proposes policies to implement the ASCRS-supported MACRA statute technical corrections enacted earlier this year.

Key 2019 MIPS Proposals:

  • 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 lowering it to 3 points and moving it to the Quality category, rather than adding it to the MIPS final score.
  • 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 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 proposes to 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. CMS proposes to maintain 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; however, no high-priority bonus points will be awarded for measures submitted through the Web Interface system. Improvement scoring remains the same for 2019. 

CMS is proposing to remove the following ophthalmology quality measures:

  • #12, Primary Open-Angle Glaucoma (POAG): Optic Nerve Evaluation;
  • #18, Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy;
  • #140, Age-Related Macular Degeneration (AMD): Counseling on Antioxidant Supplement.

Cost Category: 15% of the 2019 MIPS Final Score

CMS proposes to 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 proposes to 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 proposes to continue its small practice accommodations in this category by awarding full credit to small practices who submit one high-weighted or two medium-weighted activities. CMS also proposes to add several new improvement activities, modify five, and remove one.

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

Following ASCRS advocacy, as part of the AMA MIPS Workgroup, CMS is proposing a major overhaul of this category to streamline and simplify the scoring. CMS proposes to eliminate the base and performance scores and replace it with a new methodology. CMS proposes 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 proposes to require 2015 certified EHR technology only for 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.