This post has been archived and contains information that may be out of date.
The Centers for Medicare & Medicaid Services (CMS) yesterday released its final rule updating the Medicare physician fee schedule (PFS) and other Medicare Part B payment policies for calendar year (CY) 2019. The final rule includes a number of significant proposals that will impact hospitals and clinicians. Included in the PFS final rule is an interim final rule that implements provisions of the recently signed Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act.
Comments on the interim final rule are due Dec. 31. CHA will release a detailed summary in the coming weeks; key provisions are highlighted below.
- 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 (PBDs) 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 finalizes its proposal to maintain the current PFS relativity adjuster at 40 percent. CMS finalized additional policies for off-campus PBDs in its CY 2019 outpatient prospective payment system final rule.
- Evaluation and Management (E/M) Burden: In a change from the proposed rule, CMS finalized a single, blended payment rate for E/M visits levels 2-4, but maintains a separate payment rate for level 5 E/M visits. CMS also delayed implementation of the new E/M payment rates until CY 2021, and finalized a number of add-on payments to account for additional complexity in level 2-4 visits. CMS has made available a table that shows the new payment rates. For CY 2019 and beyond, CMS finalized a number of documentation burden reduction policies as proposed, such as allowing practitioners to review and verify certain information in the medical record entered by ancillary staff or the beneficiary, rather than re-entering the information themselves.
- Part B Drugs: Despite opposition from CHA and other stakeholders, CMS finalized its proposal 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 will apply only to drugs that do not have average sales price data.
- Clinical Laboratory Fee Schedule (CLFS): CMS finalized its proposal 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 expands the definition of applicable laboratory to include many hospital outreach laboratories. Hospitals should carefully review these provisions of the final rule to determine if the revised definitions will require them to begin collecting and reporting their private payer payment rates and volumes during the upcoming CLFS data collection and reporting periods.
- Therapy Services: Because the Bipartisan Budget Act of 2018 repealed therapy caps, CMS discontinues 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. In the final rule, CMS establishes two new therapy modifiers to implement this provision, on which reporting will be required beginning Jan. 1, 2020.
- Appropriate Use Criteria (AUC): CMS clarified that the reporting of AUC information will be required both on professional and facility claims, and moved forward with its proposal to use G-codes and modifiers to report this information for claims beginning in 2020. CMS also finalized proposals to allow AUC consultations to be performed by clinical staff under the direction of the ordering professional, to revise the significant hardship criteria in the AUC program and to add independent diagnostic testing facilities as a setting for the program.
- Telehealth Services: CMS finalized a number of policies that implement 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. As required by the SUPPORT Act, CMS also issued an interim final rule that makes the same changes to treat beneficiaries with substance use disorders. In addition, CMS will 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 — as well as for interprofessional internet consultations and chronic care remote physiologic monitoring.
- Quality Payment Program: CMS finalized 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 expanded the definition of “MIPS-eligible clinicians” to include physical therapists, occupational therapists, clinical social workers and clinical psychologists. CMS also reduced the MIPS measure set and overhauled the MIPS Promoting Interoperability performance category to align with changes finalized for the hospital program. CMS also finalized a policy to automatically attribute clinicians eligible for the facility-based measurement option, which allows qualifying clinicians to be scored using their hospital’s value-based purchasing program performance, rather than reporting separate MIPS cost and quality data.
