CMS finalizes 2019 rules

CMS has issued its final 2019 rule for both the Physician Fee Schedule (PFS) and the Quality Payment Program (QPP), which includes the Merit-based Incentive Payment System (MIPS).

“Today’s rule finalizes dramatic improvements for clinicians and patients and reflects extensive input from the medical community,” CMS Administrator Seema Verma said in a statement. “Today’s rule offers immediate relief from onerous requirements that contribute to burnout in the medical profession and detract from patient care. It also delays even more significant changes to give clinicians the time they need for implementation and provides time for us to continue to work with the medical community on this effort.”

Under the final QPP rule, MIPS-eligible clinicians will be required to use a 2015 Edition certified EHR as of Jan. 1, 2019. CMS says this change is necessary so patients can more easily access their data and information can more easily be shared among doctors and other providers. But Ana Maria Lopez, MD, MACP, president of the American College of Physicians, has concerns, especially with the short implementation timeline. "Rushing implementation of these upgrades to meet a reporting deadline can have serious patient safety risks and is a major expense and burden, particularly to small practices," Lopez said in a statement.

CMS also added an additional low-volume threshold exemption to MIPS for next year. To be excluded, providers or groups need to meet at least one of the following conditions:

• Have $90,000 or less in Medicare Part B allowed charges for covered professional services.
• Provide care to 200 or fewer Part B-enrolled patients.
• Provide 200 or fewer covered professional services under the PFS.

The minimum period for each performance category remains unchanged, so quality and cost stay at 12 months while improvement activities and promoting interoperability remain at a continuous 90-day period.

However, the weighting to the final score of the cost and quality categories have both changed. Cost increases from 10 percent to 15 percent of the total score, and quality drops from 50 percent to 45 percent.

Changes to the fee schedule

Changes to the 2019 PFS include the following:

• Elimination of the requirement to document the medical necessity of a home visit in lieu of an office visit.
• For established patients, when relevant information is already in the medical record, practitioners can focus documentation on what has changed since the last visit. Practitioners don’t need to re-enter the defined list of required elements if there so long as they have reviewed and updated the previous information as needed.
• Practitioners need not re-enter information on the patient’s chief complaint and history that has already been entered by ancillary staff or the patient.
• Removal of the potentially duplicative requirements for notations in medical records that may have previously been included by residents or other members of the medical team for E/M visits furnished by teaching physicians.

The final 2019 PFS rule also adds payments for some telemedicine services, as follows:

• Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012)
• Remove evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010).

According to CMS, practitioners could be separately paid for the brief communication technology-based service when the patient checks in via phone or other telecommunication device to decide whether an office visit or service is needed. Similarly, the remote evaluation of video or images submitted by an established patient would allow payment for reviewing the information to determine the necessity of an office visit.

One proposal that did not make it in the 2019 final rule involved the collapsing of E/M codes. CMS proposed paying a single rate for E/M office/outpatient visits with levels two through four while maintaining the payment rate for level five, among other changes. These E/M changes have been deferred to 2021, but the Medical Group Management Association (MGMA) says the proposal needs more refining.

“We welcome CMS’s deferral and revision of the collapsed E/M codes to 2021, but there's more work to be done,” MGMA said in a statement. "Blending payments rates in 2021 won't necessarily reduce burden, especially with CMS’ newly required add-on codes. MGMA will continue to examine the rule, leverage feedback from members, and work with CMS to create meaningful burden reduction for physician practices across the country."

Lopez said the ACP has reservations about paying level four visits, the second most complex visit, at the same amount as levels two and three. “Internists appreciate CMS’ decision not to finalize changes in payments for evaluation and management services until 2021. We are hopeful that the additional two calendar years leave time for physicians and other health care stakeholders to work together with regulators to develop and test alternatives that preserve higher payment for more complex, cognitive care,” she said.

The American Medical Association also supported with the delay. “The AMA also is grateful that the Administration is not moving forward in 2019 with the payment collapse of E/M codes,” said AMA President Barbara L. McAneny, MD, in a statement. “A two-year window for implementation of the proposal will give the AMA-convened workgroup-comprised of physicians and other health professionals -time to make recommendations on this complicated topic.”

Overall, William S. Mayo, DO, president of the American Osteopathic Association, said he is pleased CMS listened to commenters’ feedback. “The AOA is grateful that CMS heeded the concerns expressed by practicing physicians about the proposed rule and looks forward to advancing the dialogue on how physician payment policy can be modified for the betterment of both physician practice and the patients we care for,” Mayo said in a statement.