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Ellen Donahue

Medicare Proposed Rule for Calendar Year 2019: PFS


Medicare Physician Fee Schedule (PFS)

Release Date: July 12, 2018
Federal Register publication date: July 27, 2018
Comments Due: 5:00 p.m. September 10, 2018
Effective Date: January 1, 2019

Medicare states its payment systems are being updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. The proposed rule includes discussions and proposals regarding:

  • Potentially misvalued codes
  • Communication technology-based services
  • Valuation of new, revised and misvalued codes
  • Payment rates under the PFS for nonexcepted items and services furnished by nonexcepted off-campus provider-based departments of a hospital
  • E/M visits
  • Therapy services
  • Clinical laboratory fee schedule
  • Ambulance fee schedule – provision in the Bipartisan Budget Act of 2018
  • Appropriate used criteria for Advanced Diagnostic Imaging Services
  • Medicaid promoting interoperability program requirements for Eligible Professionals (EPs)
  • Medicare Shared Saving Program Quality measures
  • Physician self-referral law
  • CY 2019 updates to the quality payment program
  • Request for Information on price promoting interoperability and electronic health information exchange through possible revisions to the CMS patient health and safety requirements for hospitals and other Medicare- and Medicaid-participating providers and suppliers
  • Request for Information on price transparency: Improving beneficiary access to provider and supplier charge information

Highlights include:

Updated Conversion Factors: PFS Anesthesia
CY 2018 Conversion Factor $35 .9996 $22 .1887
  CY 2019 Statutory Update Factor    0 .250%    0 .250%
  CY 2019 RVU Budget Neutrality
  (0 .120%)   (0 .120%)
  CY 2019 Anesthesia Fee
  Schedule Practice Expense
  and Malpractice Adjustment
   0 .000%    0 .365%
CY 2019 Conversion Factor $36 .0463 $22 .2986

E/M Visits:

CMS is proposing changes to streamline the administrative burden and improve payment accuracy for Evaluation and Management (E/M) visits. The PFS proposed rule also attempts to improve payment accuracy and simplify documentation by having a single blended payment rate for new and established patients for office/outpatient E/M Level 2 through 5 visits. CMS also proposed a series of add-on codes for resources involved in furnishing primary care and non-procedural specialty generally recognized services.

Communication Technology-based services:

Proposals are made for reimbursement for communication technology-based services in CY 2019 using two newly defined procedures of:

  • Brief communication technology-based service, e.g. virtual check in (GVCI1)
  • Remote evaluation of recorded video and/or images submitted by the patient (GRAS1)

Part B Drug add-on:

An add-on for a subset of Part B Drugs is being proposed at Wholesale Acquisition Cost (WAC)-based payments plus 3% for CY 2019 rather than the current add-on of 6%.

Payment rates for nonexcepted services:

Medicare directs the readers of the Proposed PFS rule to the CY 2019 OPPS/ASC proposed rule for discussions on issues related to the excepted (grandfathered) and nonexcepted status of off-campus PBDs and the applicable excepted status of items and services. CMS is proposing to maintain the PFS relativity adjuster at 40% for CY 2019 to approximate 40% of what grandfathered items and services would have been paid under OPPS. Medicare is attempting to encourage fairer competition between hospitals and physician practices by more closely aligning payment between care settings.

Therapy services:

Modifiers have been established to identify when services are furnished in whole or in part by a physical therapy assistant (PTA modifier) or an occupational therapy assistant (OTA modifier). These new modifiers will be used in conjunction with the three existing modifiers. These modifiers are not required on claims until January 1, 2020 and will be used to ensure payments using these modifiers are paid at 85% of the applicable Part B payment amount effective January 1, 2022.

RHCs and FQHCs:

Effective January 1, 2019 CMS is proposing RHCs and FQHCs receive an additional payment for the costs of communication technology-based services or remote evaluation services that are not already captured in the RHC AIR (All Inclusive Rate) or the FQHC PPS payment when the requirements are met. See Communication Technology-based services for discussion of applicable services. There are certain restrictions to billing for these services.

If you wish to have additional information please contact Ellen Donahue.

Source: Proposed Policy, Payment and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019
Released: July 12, 2018