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Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?

November 7th, 2018 - Wyn Staheli, Director of Research
Categories:   Medicare   Reimbursement   CPT® Coding   Evaluation & Management (E/M)   MIPS|PQRS|PQRI  
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The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and Management codes for office visits, but that's not all that was included in this 2,300+ page document. The following is a summary of some of the major provisions.

Evaluation & Management

CMS' stated goal was to reduce administrative burden when reporting these services. Some changes are happening right away and some will happen later. The following take effect January 2019:

Not all of the proposed changes relating to E/M services happened. The following office and outpatient visit changes were finalized, but they will not take place until 2021:

The following proposed changes were NOT finalized and thus will not be implemented:

Expand Technology & Telehealth Services

There are new codes to describe services rendered by healthcare providers using technology-based services. There are both telehealth codes as well as services that use technology services, but in and of themselves are not a telehealth service. Those services that are not telehealth but use technology to render the service are not subject to Medicare’s requirements for telehealth services (e.g., originating site, patient located in a rural or health professional shortage area).

CMS is also expanding coverage for communication technology-based services and remote evaluation services furnished by Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) when there is not another associated billable visit. This will be billed with the new code G0071.

Medicare will cover the following new codes:

G0071 — Virtual Communication

G2012 — Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional

G2010 — Remote evaluation of recorded video and/or images submitted by an established patient

99453, 99454, 99457 — Remote physiologic monitoring

99451, 99452 — Interprofessional Telephone/Internet/Electronic Health Record Consultations

See the Fact Sheet by the Center for Connected Health Policy, located in the References, for more about these services.

Telehealth Expansion

Medicare will also be adding the following to their approved telehealth coverage:

Substance Use Disorders Treatment

Assistants

Functional Reporting

Beginning in January 2019, functional reporting will no longer be required for reimbursement by Medicare. PTs, OTs, and SLPs will not be required to report HCPCS codes G8978-G8999 or G9158-G9186. Also, severity modifiers CH through CN will not be required. The codes are still going to be valid for a little while to allow providers and insurers time to update their billing systems and policies (and thus, avoid claim rejections due to inadvertent non-payable code submission).

If you want, you can continue to report the codes, they just aren’t required for payment. It should be noted that even though they aren’t required for payment, they may be used by MIPS-eligible PTs, OTs, and SLPs for MIPS quality reporting in 2019.

Low Volume Threshold & MIPS Participation

Low volume thresholds for MIPS participation were also revised. Beginning in 2019, if one of the following statements holds true for a MIPS-eligible clinician or group, they will not be required to participate in MIPS:

Even if you are not required to participate, you can choose to either opt-in to MIPS or voluntarily report. Clinicians and groups have the opportunity to opt in to MIPS if they only meet one or two of the three low-volume thresholds listed above. If you meet all three, then you may NOT opt in but you could still participate voluntarily and obtain feedback about your reporting. Those who voluntarily report quality data will experience no MIPS payment adjustments. Those who decide to opt in for 2019 will experience payment adjustments (positive, neutral or negative) in the 2021 payment year.

In order to opt in or voluntarily report, you MUST log into the Quality Payment Program portal and select the applicable option.

Other

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