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The Centers for Medicare & Medicaid Services (CMS) yesterday released its proposed rule updating the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies for calendar year (CY) 2019. The proposed rule includes a number of significant proposals that will impact hospitals and clinicians. While CHA will release a detailed summary of the proposed rule in the coming weeks, key provisions are highlighted below. Comments on the proposed rule are due Sept. 10.
- Payment for Non-Excepted Off-Campus Provider Departments: As required by Section 603 of the Bipartisan Budget Act of 2015, CMS pays for items and services furnished at certain off-campus hospital outpatient provider-based departments under a PFS relativity adjuster of 40 percent of the amount that would have been paid for those services under the outpatient prospective payment system. For CY 2019, CMS proposes to maintain the current PFS relativity adjuster at 40 percent.
- Evaluation and Management (E/M) Burden: CMS proposes a number of coding and payment changes to reduce the administrative burden and improve payment accuracy for E/M visits. Among the changes, CMS proposes to expand options on how practitioners choose to document E/M visits using medical decision-making or time instead of applying the current documentation guidelines. Practitioners would be allowed to review and verify certain information in the medical record entered by ancillary staff or the beneficiary, rather than re-entering the information themselves. CMS also proposes to establish a new, single blended payment rate for new and established office and outpatient E/M level 2 through 5 visits.
- Part B Drugs: CMS proposes to reduce payment for new Part B drugs from the rate of wholesale acquisition cost (WAC) plus 6 percent to WAC plus 3 percent. This rate would apply only to drugs that do not have average sales price data.
- Telehealth Services: CMS proposes to implement a number of provisions of the Bipartisan Budget Act of 2018 relating to telehealth services, including changes to originating site geographic requirements for end-stage renal disease beneficiaries and for telestroke services. In addition, CMS proposes to pay separately for two new virtual services: telephone “check-ins” between clinicians and beneficiaries and the remote evaluation of photos or videos that a patient submits to a clinician.
- Therapy Services: Because the Bipartisan Budget Act of 2018 repealed therapy caps, CMS proposes to discontinue the functional status reporting requirements for therapy services furnished on or after Jan. 1, 2019. The legislation also required CMS to reduce payment for outpatient services provided in whole or part by a physical therapy assistant or occupational therapy assistant to 85 percent of the applicable Part B payment amount beginning Jan. 1, 2022. CMS proposes to establish two new therapy modifiers to implement this provision, on which reporting would be required beginning Jan. 1, 2020.
- Appropriate Use Criteria (AUC): CMS proposes to revise the significant hardship criteria in the AUC program to include insufficient internet access, electronic health record or clinical decision support mechanism vendor issues, and extreme and uncontrollable circumstances.
- Clinical Laboratory Fee Schedule: CMS proposes to expand the definition of applicable laboratory for determining the payment rates for the clinical laboratory fee schedule by changing the treatment of Medicare Advantage payments in determining Medicare revenue thresholds. In addition, CMS seeks comments on alternative approaches for defining an applicable laboratory, as well as potential changes to the low expenditure threshold component of the definition of an applicable laboratory.
- Medicare Shared Savings Program: In support of its Meaningful Measure Initiative, CMS proposes to reduce the total number of measures in the Shared Savings Program quality measure set from 31 to 24 and focus the measure set on more outcome-based and patient experience of care measures.
- Quality Payment Program: CMS proposes provisions implementing the third year of the quality payment program for physician payment, including requirements for the Merit-Based Incentive Payment System (MIPS) and incentives for advanced alternative payment model participation. Among the significant changes for MIPS, CMS proposes to expand the definition of MIPS-eligible clinicians to include physical therapists, occupational therapists, clinical social workers and clinical psychologists. CMS also proposes to reduce the MIPS measure set and to overhaul the MIPS Promoting Interoperability performance category to align with changes proposed for the hospital program. CMS also proposes testing the Medicare Advantage Qualifying Payment Arrangement Incentive demonstration, which would test waiving MIPS reporting and payment adjustments for clinicians who participate sufficiently in Medicare Advantage arrangements that are similar to Advanced APMs.
