Physician Payment and Reimbursement

CY2019 Medicare Physician Fee Schedule Proposed Rule

September 28, 2018 11:37 am

HFMA Executive Summary

On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) placed on public display a proposed rule relating to the Medicare physician fee schedule (PFS) for CY 2019 and other revisions to Medicare Part B policies. The proposed rule is scheduled to be published in the July 27, 2018, Federal Register. If finalized, policies in the proposed rule generally would take effect on January 1, 2019. The 60-day comment period ends at close of business on September 10, 2018.

The rule includes a proposal related to office/outpatient evaluation and management (E/M) codes; CMS proposes alternatives for documenting the appropriate level of E/M visit, and a single payment rate for established E/M visits. CMS also proposes to pay separately for two newly defined physicians’ services using communication technologies.

2019 Proposed Conversion Factor 

The proposed conversion factor for CY 2019 is $36.0463, which reflects the 0.25 percent update adjustment factor specified under the Balanced Budget Act of 2018 (BBA 18), and a budget neutrality adjustment of -0.12 percent (2018 conversion factor is $35.9996×1.0025×0.9988=$36.0463).

  • The 2019 proposed anesthesia conversion factor is $22.2986 (compared to CY 2018’s $22.1887), which reflects the same adjustments, and an additional adjustment due to an update to the malpractice risk factor for the anesthesia specialty.

Specialty Specific Impact
The most widespread specialty impacts of the proposed relative value unit (RVU) changes are generally related to those for specific services resulting from the Misvalued Code Initiatives, including the establishment of proposed RVUs for new and revised codes. CMS states that the specialty level impacts in the rule are being driven by its proposal related to office/outpatient E/M codes, which comprise a large volume of services in the PFS. 

Quality Payment Program (QPP)
For the 2019 performance period (payment in 2021), CMS proposes to modify the definition of a Merit-based Incentive Payment System (MIPS) eligible clinician to include the following eligible clinician types: physical therapist, occupational therapist, clinical social worker, clinical psychologist, and a group that includes such clinicians. In addition to renaming the “Advancing Care Information” performance category the “Promoting Interoperability” category, CMS proposes a new scoring methodology based on a combination of measures instead of the current base, performance, and bonus score methodology.

Medicare Shared Savings Program (MSSP)
CMS proposes changes to the quality performance measures in the Patient Experience of Care Survey measures, and the CMS Web Interface and Claims-Based measures for the 2019 performance year and subsequent years. CMS also proposes several changes to the quality measure set used to assess quality performance of Accountable Care Organizations under the Shared Savings Program. CMS believes that the changes would enhance patient and caregiver experience, and would better align with MIPs.

Medicaid Promoting Interoperability Program Requirements for Eligible Professionals 
CMS proposes to align the electronic clinical quality measures (eCQMs) for Medicaid eligible professionals (EPs) with those available for MIPS eligible clinicians for the CY 2019 performance period by making the list of quality measures for Medicaid EPs the same as the list proposed for MIPS. The Medicaid EPs would report on any six eCQMs that are relevant to the EP’s scope of practice. 

Physician Self-Referral Law
Under the proposal, CMS would revise its regulations regarding the rules under the Stark law to address any actual or perceived difference between the statutory and regulatory language, codify its policy on satisfying the writing requirement in many Stark law exceptions, and apply Section 50404 of the BBA 18 policies applicable to compensation arrangements that it has created through its authority under the law.

RFIs on Promoting Interoperability and Price Transparency
CMS seeks public comment on how best to accomplish the goal of fully interoperable health information technology and electronic health record systems for providers and suppliers, and how to advance the MyHealthEData initiative for patients. Additionally, in order to promote greater price transparency for patients, CMS is considering ways to improve the accessibility and usability of current charge information. Specifically, it seeks comments on potential actions to further its objective of having providers and suppliers engage in consumer-friendly communication of their charges to help patients understand what their potential financial liability might be for obtained healthcare services. 


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