A Guide to Regulation and Legislation Volume Eighteen

Regulatory Advisor Volume Eighteen offers a concise summary of key changes to payment and policies that will be affected by the final rule.

Navigating health reform

CMS’ 2019 Physician Fee Schedule Final Rule

  • Penny Osmon Bahr
  • 12/3/2018

On November 1, 2018, the Centers for Medicare and Medicaid Services (CMS) released the CY 2019 final Physician Fee Schedule (PFS), which includes final changes to Evaluation and Management (E/M) documentation guidelines in physician offices, adds payment for two new telecommunication services, and outlines several other key finalized changes.

This regulatory advisor includes a high level overview of key provisions in the PFS Final Rule. It does not address the Quality Payment Program (QPP) portion of the rule, as that information will be covered in a forthcoming regulatory advisor. Unless otherwise indicated, CMS is the source of all data presented. You can find information on the 2019 PFS relative adjuster for off-campus provider-based hospital outpatient departments in Regulatory Advisor Volume Seventeen.

Communication technology-based services

In an effort to expand Medicare beneficiary access to care, two new communication technology codes were finalized for implementation in 2019. The services are not intended to replace any in-person visits, but rather to reduce unnecessary office visits. The first new service, a Brief Technology-Based Service, allows for providing a “brief check-in” to assess whether an established patient’s condition necessitates an office visit.

  • G2012: Brief Communication Technology-Based Service (e.g. virtual check-in): Brief communication technology-based service by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment, 5 – 10 minutes of medical discussion.
    Finalized work relative value unit (wRVU) of 0.25 and is based on an estimate of 5 – 10 minutes of medical discussion.

This service is intended to be initiated by the patient and will have routine cost sharing. The service is billable if the patient does not need to be seen within 24 hours of the communication or the next available appointment. It is important to note that the final rule clarifies that phone calls with clinical staff and “incident-to” services are not permitted. A virtual check-in requires direct interaction with the billing practitioner, and verbal consent from the patient must be obtained and documented.

There will be no further service-specific documentation requirements, although the service must still be medically necessary and reasonable. The communication must also not be related to any global surgical period. CMS further notes this service can be used as part of a treatment regimen for opioid use disorders and other substance use disorders, specifically Medication Assisted Therapy (MAT). CMS will monitor the billing data to determine if frequency limits are necessary.

Communication technology types defined

Acceptable technology mediums will include audio-only real-time telephone interactions and synchronous, two-way audio interactions that are enhanced with video, or other kinds of data transmission.

The second new communication technology service finalized for 2019 is Remote Evaluation of Pre-Recorded Patient Information, and allows for “store-and-forward” asynchronous transmission of pre-recorded patient-generated still or video images. Written or verbal consent, including electronic documentation, must be obtained due to the implication of cost sharing.

  • G2010: Remote Evaluation of Pre-Recorded Patient Information: Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with verbal follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.
    Finalized wRVU of 0.18

Verbal follow-up can be accomplished via phone call, audio/video communication, secure text messaging, email, or patient portal communication.

Remote patient monitoring codes added

In the PFS CY2018 final rule, CMS adopted CPT® code 99091 for remote patient monitoring. At that time, CMS indicated there would be new codes forthcoming from the CPT Editorial Panel and the RUC. The following remote patient monitoring codes are active for 2019.

  • 99457: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.
    Finalized wRVU of 0.61
  • 99453: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.
  • 99454: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.

Both CPT® codes 99435 and 99454 are PE-only codes.

Changes to telehealth

Telehealth preventive services added for 2019

Two new telehealth services for Prolonged Preventive Services(s) for use in the office or outpatient setting were finalized.

  • G0513: Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service, first 30 minutes.
  • G0514: Each additional 30 minutes.

These services will only be available in the office or the outpatient setting.

Finalized coverage for end-stage renal disease (ESRD) and telestroke

Several telehealth provisions of the Bipartisan Budget Act of 2018 will be implemented on January 1, 2019, and include coverage for:

  • Monthly ESRD-related clinical assessments when the originating site is a hospital-based or critical access hospital-based renal dialysis center, a renal dialysis facility, or the home of an individual. (There is no originating site facility fee paid a when the originating site for these services is the patient’s home.)
  • ED visits for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke furnished beyond traditional “originating sites” to include any hospital, critical access hospital, mobile stroke, or any other site determined appropriate by the Secretary.
    • CMS finalized a new modifier that would be used to identify acute stroke telehealth services. The modifier will be used by both the originating and distant site. CMS intends to communicate the selected modifier by the end of 2018.
    • CMS finalized the definition of a mobile stroke unit to include telehealth originating sites and all hospitals and critical access hospitals, while excluding renal dialysis facilities and the patient’s home.

Expansion of Medicare telehealth services for the treatment of opioid use disorder and other substance use disorders

On October 24, 2018, the SUPPORT Act was passed, which outlines expanding Medicare telehealth services for the treatment of opioid use disorder and other substance use disorders.

The legislation removed the originating site geographic requirements for telehealth services furnished on or after July 1, 2019, for the purpose of treating individuals diagnosed with a substance use disorder or a co-occurring mental health disorder. It also adds a patient’s home as a permissible originating site for these telehealth services, and there will be no originating site fee paid when services occur in the home setting.

Clinicians will be responsible for assessing whether individuals have a substance use disorder diagnosis, and whether it would be clinically appropriate to furnish telehealth services for the treatment of the individual’s substance use disorder or a co-occurring mental health disorder.

The SUPPORT Act also establishes a new Medicare benefit category for opioid use disorder treatment services furnished by Opioid Treatment Programs (OTP) under Medicare Part B, beginning January 1, 2020. OTPs are defined as those that enroll in Medicare and are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA), accredited by a SAMHSA-approved entity, and those that need additional conditions as the Secretary finds necessary to ensure the health and safety of individuals being furnished services under these programs.

Evaluation and management

Six interprofessional services finalized for reimbursement

To support the evolving ecosystem of team-based care, six interprofessional services were finalized for payment in 2019. The codes consist of two new services and four additional codes that were previously bundled by Medicare. These codes describe assessment and management services conducted through the telephone, internet, or electronic health record furnished when a patient’s treating physician or other qualified health care professional requests the opinion and/or treatment advice of a consulting physician or qualified health care professional with specific specialty expertise to assist with the diagnosis and/or management of the patient’s problem.

  • 99451: Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional; five or more minutes of medical consultative time
    Finalized RVU of 0.70
  • 99452: Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional; 30 minutes
    Finalized wRVU of 0.70
  • 99446: Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 5 – 10 minutes of medical consultative discussion and review.
    Finalized wRVU of 0.35
  • 99447: Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician in qualified health care professional; 11 – 20 minutes of medical consultative discussion and review.
    Finalized wRVU of 0.70
  • 99448: Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 21 – 30 minutes of medical consultative discussion and review.
    Finalized wRVU of 1.05
  • 99449: Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review.
    Finalized wRVU of 1.40

Billing physicians must obtain verbal consent from the patient in advance of these services and document it in the medical record. Cost sharing will apply when these services are billed.

Documentation guideline and reimbursement changes

CMS received thousands of comments and has modified and delayed many of the proposed changes until 2021. The two-year delay in implementation will provide the opportunity for CMS will work with the American Medical Association and the CPT Editorial Panel, as well as other stakeholders, in rolling out the 2021 changes.

The documentation guideline final changes will only apply to office/outpatient visit codes (CPT® codes 99201 – 99215). Practitioners should continue to use the 1995 and 1997 documentation guidelines in 2019 and 2020, with the exception of finalized changes outlined in this section. The finalized changes are designed to reduce redundancy in data recording.

Providing choices in documentation

Beginning in 2021, clinicians billing Medicare for level 2 – 5 office/outpatient E/M visits will be allowed to choose how to document for code level selection. They may continue using a current framework (95 or 97 guidelines) or select the level of E/M service based entirely on Medical Decision Making or use total time as a basis to determine the appropriate level of E/M visit. CMS also finalized the minimum documentation standard, which will require clinicians to meet documentation requirements currently associated with a level two visit for levels 2 – 4 (99202-99204 and 99212-99214), unless choosing to document based on time.

Minimum documentation standard requirements

The following is the minimum E/M documentation standard (at a level two visit) when applying the current 95/97 guideline framework:

  • Problem-focused history that does not include a review of systems or a past, family, or social history
  • A limited examination of the affected body area or organ system
  • Straightforward medical decision-making measured by minimal problems, data review, and risk (two of these three).

Alternatively, if the clinician chooses to document based on MDM alone, Medicare would only require documentation supporting straightforward medical decision-making measured by minimal problems, data review, and risk (two of these three).

The move to a single payment rate

Stakeholders agreed that the current set of CPT® codes for new and established office-based and outpatient E/M visits and their respective payment rates no longer appropriately reflect the complete range of services and resource costs associated with furnishing these services.

CMS is finalizing changes to E&M reimbursement to be effective January 1, 2021. Specifically visit levels 2 – 4 will have one payment rate, one for new (99202 – 99204) and one for established (99212 – 99214) patients. In a change from the final rule, visit level five (99205 and 99215) will continue to be paid at a higher rate to account for the complexity of these patient types. The 2012 rates will be $130 for a new patient visit and $90 for an established.

Removing redundancy in history and exam and chief complaint documentation

CMS finalized the proposal to simplify the documentation of history and exam for established patients, and will only require clinicians to document what has changed since the last visit rather than re-documenting a defined list of required elements applicable to review of systems and family/social history. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so. This policy is to simplify and reduce redundancy in documentation and is optional for practitioners. Practitioners may choose to continue the current process of entering, re-entering, and bringing forward information, especially those who lack time prior to 2019 to change workflows.

Further, CMS finalized giving clinicians the option to no longer re-enter information in the medical record regarding the chief complaint that is already entered by ancillary staff or the patient for both new and established patients.

New codes for visit complexity finalized for 2021

CMS is finalizing the creation of two new G-codes with slight modification, including the addition of “non-procedural” to the specialty complexity add-on code. CMS notes that when clinical circumstances support it, practitioners not enrolled among the specialties expressly listed within the code descriptor may still bill the inherent visit complexity add-on codes.

  • GCG0X: Visit complexity inherent to evaluation and management associated with nonprocedural specialty care, including endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, interventional pain management, cardiology, nephrology, infectious disease, psychiatry, and pulmonology. (Add-on code, list separately in addition to level 2 – 4 office/outpatient evaluation and management visit, new or established.)
    Finalized wRVU of 0.25, MP RVU of 0.02 and 8.25 minutes
  • GPC1X: Visit complexity inherent to evaluation and management associated with primary medical care services that serve as the continuing focal point for all needed health care services. (Add-on code, list separately in addition to level 2 – 4 office/outpatient evaluation and management visit, new or established.)
    Finalized wRVU of 0.25, MP RVU of 0.02 and 8.25 minutes

Eliminating extra documentation requirements for home visits

Effective January 1, 2019, CMS finalized the proposal to remove the requirement that the medical record must document the medical necessity of furnishing the visit in the home rather than in the office.

Eliminating prohibition on billing same-day visits by practitioners of the same group and specialty

Not finalized. Current practice indicates that there is often a workaround that includes scheduling E/M visits on two separate days, which could unnecessarily inconvenience the patient. Since it is becoming more common for clinicians to have multiple specialty affiliation, CMS sought and received several comments on whether elimination of this provision could have unintended consequences for clinicians and patients. CMS will continue to review the comments and make recommendations through future rule-making.

The multiple procedure reduction of 50 percent

Not finalized. As part of the proposal to make payment for E/M levels 2 – 5 at a single PFS rate, CMS further proposed to reduce payment by 50 percent for the least expensive procedure or visit that the same physician (or a physician in the same group practice) furnished on the same day to the same patient identified on the claim by modifier -25.

Extended services finalized for 2021

Currently, clinicians have an option to use a prolonged service codes 99354 (one hour) and 99355 (each additional 30 minutes) to report direct patient contact beyond the base time of the E/M reported. Stakeholders have indicated it is often difficult to meet the threshold of 31 minutes in order to bill CPT® 99354. As part of the movement to create a single payment rate for visit levels 2 – 4, CMS finalized extending services with a new prolonged E/M code reducing time to 30 minutes. This means a clinician would only need to meet a threshold of 16 minutes in order to bill CPT® 99354.

  • GPRO1: Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; 30 minutes
    Finalized wRVU of 1.17

Separate codes for podiatric evaluation and management services were not finalized

Relative to the proposed changes, almost all comments received by CMS did not support the overall coding and payment changes for E&M, including podiatric services.

New code finalized for alcohol and substance assessments

CMS finalized the proposal to reduce the documentation burden for these services in 2019, and is adding a third option with a lower time threshold when clinicians are unable to meet the original code thresholds. CMS is also eliminating service specific documentation.

  • G2011: Alcohol and/or substance (other than tobacco) abuse structured assessment (e.g., AUDIT, DAST) and brief intervention, 5 – 14 minutes.
    Proposed wRVU of 0.33
Direct supervision for diagnostic testing performed by radiologist assistants

As a result of the request for information on CMS Flexibilities and Efficiencies (RFI) and comments received through the rule-making process, CMS finalized that all diagnostic imaging tests may be furnished under the direct supervision of a physician when performed by a radiology assistant (RA) in accordance with state law and state scope of practice rules. RA designation includes registered radiologist assistants (RRAs) who are certified by The American Registry of Radiologic Technologists, and radiology practitioner assistants (RPAs) who are certified by the Certification Board for Radiology Practitioner Assistants.

New chronic care management code finalized

Beginning in 2019, Chronic Care Management (CCM) services furnished by a clinician (as opposed to other clinical staff) will be reported with new code 99491 under the PFS.

  • 99491: Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month, with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline; comprehensive care plan established, implemented, revised, or monitored.
    Finalized wRVU 1.45
Impact of rural health clinics (RHCs) and federally qualified health centers (FQHCs)

This new code will also be included in the calculation of the PFS amount for code G0511, created in 2018 to be used when 20 minutes or more of CCM services are provided by clinical staff of a FQHC or RHC. Payment for G0511 will be based on the average of the national non-facility PFS payment rates for CPT codes 99490, 99487, 99484, and 99491.

Communication technology-based services and remote evaluations extend to RHCs and FQHCs

CMS finalized the proposal to extend separate payment for communication technology-based services to RHCs and FQHCs. The RHC and FQHC face-to-face requirements will be waived, and both G2012 for communication technology-based services and G2010 for remote evaluation services will be separately paid under the PFS at a rate that reflects the resource costs of these non-face-to-face services relative to other PFS services, including face-to-face and in-person visits.

Effective January 1, 2019, RHCs and FQHCs will receive an additional payment for the costs of communication technology-based services or remote evaluation services that are not already captured in the RHC all-inclusive rate (AIR) or the FQHC Prospective Payment System (PPS) payment when the requirements for these services are met. At least five minutes of communications-based technology or remote evaluation services are required to be furnished by a RHC or FQHC practitioner to a patient that has been seen in the RHC or FQHC within the previous year. Coinsurance will apply to FQHC claims, and coinsurance and deductibles will apply to RHC claims when these services are performed. There is no impact to services currently paid under the RHC AIR or FQHC PPS payment methodology.

New modifiers for assistant therapy services not finalized

The CMS did not finalize a proposal to create two new therapy modifiers, which would replace modifiers GP and GO. Instead, CMS agreed with commenters who indicated that two new reimbursement modifiers should be created to use alongside the GP and GO modifiers for reimbursement purposes only. To comply with section 53107 of the Bipartisan Budget Act of 2018, beginning in January of 2020, payment will be made at 85 percent of the Part B payment amount for assistant therapy services. The reduced payment rate is not applicable to outpatient therapy services furnished by critical access hospitals.

For wholesale acquisition cost (WAC), CMS finalized the proposal to move to a 3 percent add-on in place of the 6 percent add-on for WAC-based payments for new Part B drugs beginning January 1, 2019.

Appropriate use criteria for advanced diagnostic imaging services modified and finalized

CMS finalized the proposal to add independent diagnostic testing facilities (IDTF) as another applicable location for appropriate use criteria (AUC). CMS further modified its proposal and will remove the use of “incident-to,” and instead allow AUC consultation to be delegated by the ordering physician to any clinical staff. It is important to note that the ordering professional is ultimately responsible for the AUC consultation, as the professional’s NPI is reported on the claim for the applicable imaging service, and it is the ordering professional who could be identified as an outlier and become subject to prior authorization based on their ordering pattern. The statute requires that AUC consultation information be included on any claim for an outpatient advanced diagnostic imaging service, including those billed and paid under any applicable payment system (e.g., PFS, OPPS, or ASC payment system).

AUC claims-based reporting

CMS finalized the proposal to use established coding methods, including new G-codes and modifiers, to report the required AUC information on Medicare claims in order to implement by January 1, 2020. CMS will continue to explore ways to implement a unique consultation identifier (UCI) in future rules. The use of a new HCPCS modifier was also finalized for reporting hardship exceptions. The modifier would indicate that the ordering clinician is self-attesting to experiencing a significant hardship. Hardship exceptions include insufficient internet access, EHR or CDSM (clinical decision support mechanism) vendor issues, and extreme and uncontrollable circumstances.

Claims for advanced diagnostic imaging services that include a significant hardship exception modifier would not be required to include AUC consultation information. The impact of this program is extensive, as it applies to every clinician who orders or furnishes advanced diagnostic imaging services, including MRI, computed tomography (CT), or positron emission tomography (PET). This change transcends almost every specialty, with a large potential impact on primary care physicians, given their scope of practice is often quite broad.

Make Your Opinion Known

There are two ways to submit comments on the final rule.

You may submit electronically or by regular, express, or overnight mail.

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1693-IFC, P.O. Box 8010
Baltimore, MD 21244-8016

Please allow sufficient time to mail comments prior to the closing of the comment period. Comments must be received by December 31 at 5p.m. ET.