Physician Payment and Reimbursement

Medicare Physician Fee Schedule Final Rule: 3 Must-Do Steps for Physicians

January 23, 2019 10:17 am

The Medicare Physician Fee Schedule for 2019 includes a variety of new policies—and new revenue opportunities for providers if they take a few key steps.

On Nov. 1, the Centers for Medicare & Medicaid Services (CMS) released the 2019 final rule for the Medicare Physician Fee Schedule. This year’s changes, and prospective future changes, support a broader strategy that aims to provide better patient care. The current changes focus on reducing administrative and clinical burden.

(pictured at right: Douglas Ardoin, MD)

As usual, the final rule is lengthy and, thankfully, comes with a fact sheet to help providers and practice administrators understand the changes. It will be important for providers to analyze and model these changes to gain a better understanding of the impact on revenue, compliance, and documentation requirements.

Below are some of the changes in the new rule that will affect providers, and initial steps they should take to enhance their performance under the new regulations. (This article does not address changes to the Quality Payment Program that are included in the rule.)

(pictured at right: Lucy Zielinski)

Payment Rates

Providers will experience a minuscule increase (0.11 percent) in the 2019 conversion factor, which is increasing slightly from $35.9996 to $36.0391. Overall, based on changes in the fee schedule, the specialties that will experience the greatest negative impact include diagnostic testing facilities (-5 percent) and pathology (-2 percent), whereas interventional radiology (2 percent) will experience a positive impact. Primary care providers (e.g., family practitioners, internal medicine, nurse practitioners, physician assistants) will experience a neutral impact on allowed charges.

Must-do: Providers should perform a payment analysis to determine the impact on their 2019 payments. The analysis should focus on the provider’s top services by CPT code, factoring in 2018 volume (based on units performed) and total payment. Total 2019 payments for the services can be compared to 2018 payments based on 2018 volume, accounting for projected changes in service mix or volume.

Documentation Requirements

For 2019 and 2020, CMS is not planning to make significant changes to the methodology for evaluation and management (E/M) codes in relation to the level of office and outpatient visits. The big change will occur in CY21, when CMS is planning to pay a single rate for all E/M office and outpatient visits in levels 2 through 4.

In 2019, providers will continue to choose from among the following guidelines to assign the level of visits: 1995 or 1997 E/M documentation guidelines, medical-decision-making only, or physician/patient face-to-face time. However, to reduce the burden and save providers time, CMS is relaxing requirements pertaining to:

  • Documenting medical necessity of home visits instead of office visits
  • Rerecording elements of previously documented information, such as medical history and physical exam
  • Redocumenting the chief complaint and history when those already have been entered by ancillary staff

Must-do: Providers should review the current process for documenting E/M codes with ancillary staff. Once the new process is mapped out, updates to electronic health record templates should be made. This step will save providers time in documenting. (For more on CY19 documentation for E/M visits, see this CMS FAQ.)

New Services

There are new revenue opportunities in the final rule, ranging from brief patient check-ins by telephone or other telecommunications device to review of prerecorded video or images from established patients. The purpose of these types of visits should be to help determine whether further treatment or service is needed.

The final rule adds these newly covered technology-based services, including virtual care (which includes check-ins) and remote patient monitoring. Additionally, there are new codes for biopsy and psychological evaluation.  

Must-do:  Providers should review the new services and consider adding them and billing for them in 2019—specifically, code G2012 (brief communication technology-based service or virtual check-in, payment averaging around $15). This step could generate an additional source of revenue while providing better patient care.

The Big Picture

Overall, the changes in the final rule continue the emphasis on providing better patient care at a reduced cost. Many additional policy items are addressed in the rule, including payment for care-management bundles; telehealth services for substance use disorders, dialysis, and stroke patients; and more. Practice administrators and finance managers should be sure to review the portions of the final rule that affect their business.

Douglas Ardoin, MD, MBA, is managing principal, Lumina Health Partners, Chicago.

Lucy Zielinski is managing partner, Lumina Health Partners, Chicago.


googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text1' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text2' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text3' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text4' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text5' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text6' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-text7' ); } );
googletag.cmd.push( function () { googletag.display( 'hfma-gpt-leaderboard' ); } );