Preliminary Analysis - Medicare Physician Fee Schedule Proposed Payment Rule for CY 2019 and Quality Payment Program Proposed Rule for 2019

Preliminary Analysis - Medicare Physician Fee Schedule Proposed Payment Rule for CY 2019 and Quality Payment Program Proposed Rule for 2019

On Thursday, July 12, 2018, the Centers for Medicare and Medicaid Services (CMS) posted the proposed Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) rule for 2019.  This comprehensive, joint rule proposes policy and payment changes under the Medicare program.  It addresses sweeping changes in Evaluation and Management (E/M) services reimbursement and documentation, valuation and payment updates for other services, an expansion of telehealth services, a reimbursement structure for health technology-based communications services, and program rules for QPP participation in 2019. 

The Academy offers a preliminary analysis of the proposed rule below.

Conversion Factor

CMS estimates a conversion factor of $36.05, an increase from the 2018 conversion factor of $35.99.

Audiology Codes Not on the List of Potentially Mis-valued Services

CMS is required to periodically identify potentially mis-valued services using certain criteria and to review and make appropriate adjustments to the relative values for those services. CMS did not identify any audiology codes on their list of potentially mis-valued services for CY 2019.

Changes in Evaluation and Management Services

CMS proposes a new payment structure and streamlined documentation requirements for evaluation and management (E/M) services.  Specifically, CMS proposes that new patient office visits (CPT 99202-99205) would be subject to a single blended payment rate of $135.00. Established patient office visits (CPT 99212-99215) would be blended and paid at $93.00.  CMS would create new codes to provide add-on payments to office visits for specific specialties and primary care.  When physicians report an E/M service and a procedure on the same date, CMS proposes a 50 percent multiple procedure payment reduction for the lower paid of the two services.

CMS proposes to allow documentation options. Instead of applying the current 1995 or 1997 E/M documentation guidelines, proposed changes include:

  • expanding current documentation options by allowing practitioners to use time as the governing factor in selecting visit level and documenting the E/M visit, regardless of whether counseling or care coordination dominate the visit;
  • expanding current options regarding the documentation of history and exam, to allow practitioners to focus their documentation on what has changed since the last visit or on pertinent items that have not changed, rather than re-documenting information, provided they review and update the previous information;
  • allowing practitioners to simply review and verify certain information in the medical record that is entered by ancillary staff or the beneficiary, rather than re-entering it. 

Payment Rates for Non-excepted Off-campus Provider-Based Hospital Departments

Statute requires that certain items and services furnished by certain off-campus hospital outpatient provider-based departments no longer be paid under the Hospital Outpatient Prospective Payment System (OPPS), effective January 1, 2017.  CMS finalized the MPFS as the applicable payment system for such services.  Since CY 2017, payment for these services has been based on a percentage amount of the OPPS payment rate. For CY 2018, the payment adjustment is 40 percent of the amount that would be paid under OPPS.  For CY 2019, CMS proposes to maintain this provision.

Telehealth and Health Communications Technologies

CMS proposes to expand access and promote more coordinated patient care through paying for use of health telecommunications technology and expansion of covered telehealth services.  These include: 

  • Paying clinicians for virtual check-ins – brief, non-face-to-face appointments via communications technology;
  • Paying clinicians for remote evaluation of videos or patient-submitted photos;
  • Paying for Interprofessional Internet Consultation;
  • Expanding Medicare-covered telehealth services to include prolonged preventive services (HCPCS G0513 and G0514)

Request for Information

In addition to the payment and policy proposals, CMS issued a Request for Information (RFI) to welcome feedback on whether providers and suppliers can and should be required to inform patients about charge and payment information for healthcare services and out-of-pocket costs, what data elements would be most useful to promote price shopping, and what other changes are needed to empower healthcare consumers.

Quality Payment Program

Current law identifies Merit-based Incentive Payment System (MIPS) – eligible clinicians as:  Physicians; physician assistants, nurse practitioners, and clinical nurse specialists; certified registered nurse anesthetists; and groups including these clinicians. Beginning with the 2021 payment year and, thus, the 2019 performance year, the Secretary of Health and Human Services may expand the definition of MIPS-eligible clinician to encompass addition types of clinicians, including qualified audiologists, physical therapists, occupational therapists, qualified speech-language therapists, clinical social workers, clinical psychologists, and dietitians and nutritionists.

Under this proposed rule, CMS is not proposing to add qualified audiologists to the definition of MIPS eligible clinicians for the 2019 performance year/2021 payment years. In concert with a broad effort to reduce provider burden and streamline Medicare’s quality reporting programs to focus on more meaningful measures, CMS proposes to remove multiple quality measures (including falls risk assessment) from the MIPS measure set.  Consequently, audiologists would have fewer than six quality measures available for MIPS reporting. Speech-language pathologists, certified nurse midwives, and dietitians/nutritionists would also all have fewer than 6 quality measures available and, thus, are not proposed for inclusion in MIPS at this time.  CMS does propose to add physical therapists, occupational therapists, clinical social workers, and clinical psychologists to the QPP.

However, CMS states that if the proposal to remove MIPS quality measures from QPP is not finalized, the number of measures available for each clinician type will be re-evaluated. If a clinician group is then determined to have at least 6 quality measures available, CMS proposes that the clinician group would be added to the definition of MIPS eligible clinician.

For those clinicians who are eligible to participate in MIPS, the proposed 2019 performance year weights are:

  • Quality - 45%
  • Cost- 15%
  • Promoting Interoperability – 25%
  • Improvement Activities- 15%


Comments on the proposed rule will be accepted until September 10, 2018.  The Academy will continue its analysis of the rule’s provisions and submit comments to CMS.  A final rule is expected on or around November 1, 2018.

Also of Interest