Navigating health reform
CMS’ 2019 Physician Fee Schedule Proposed Rule
The CY 2019 proposed Physician Fee Schedule (PFS) includes significant changes to evaluation and management (E/M) documentation guidelines and reimbursement in physician offices, adds payment for two new telecommunication services, reduces resident documentation again, and outlines several other key proposed changes.
This Regulatory Advisor includes a high level overview of key provisions in the Physician Fee Schedule Proposed Rule.
Due to many broad changes, a separate Regulatory Advisor will address the Quality Payment Program (QPP) portion of the rule.
Additionally, we will not cover provisions such as implementing physician self-referral technical revisions, establishing the 2019 PFS relative adjuster for off-campus provider-based hospital outpatient departments, allowing Medicare Advantage plans to be included in the Medicare revenues threshold for the Clinical Laboratory Fee Schedule, and other more technical provisions. (See our Regulatory Advisory focused on the proposed 2019 OPPS/ASC rule for further details.) The comment deadline is September 10, 2018.
In an effort to expand Medicare beneficiary access to care, two new communication technology codes are proposed for debut in 2019. The services are not intended to replace any in-person visit, but rather provide for supplemental visit opportunities. The first new service, a Brief Technology-Based Service, allows for providing a “brief check-in” to assess whether established patient’s condition necessitates an office visit.
- GVCI1: Brief Communication Technology-Based Service, e.g., Virtual Check-In: Brief communication technology based service, e.g. virtual check-in, 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.
Proposed 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 would have routine cost sharing. The service is billable if the patient is not required to be seen within 24 hours of the communication or at the next available appointment. The communication must also not be related to any global surgical period. CMS notes this service could be used as part of a treatment regimen for opioid use disorders and other substance use disorders, specifically mentioning the ability to deliver several components of Medication Assisted Therapy (MAT) that could be done virtually.
CMS is seeking comments on the types of communication common in practice today, including whether audio-only telephone interactions are sufficient compared to interactions that include video or other kinds of data transmission. They are also seeking feedback on how best to ensure consent is obtained and documented and how medical necessity is captured.
The second new communication technology service introduced for 2019 is Remote Evaluation of Pre-Recorded Patient Information and allows for “store-and-forward” asynchronous transmission communication technology, which by definition, excludes it from Medicare’s telehealth benefit.
- GRAS1: Remote Evaluation of Pre-Recorded Patient Information: Remote evaluation of recorded video 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 seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.
Proposed wRVU of 0.18 and is based on of three preservice minutes, four minutes of intraservice time, and two minutes of post-service time.
Beginning in 2019, CMS will accept requests to add services to the telehealth benefit through February 10 as opposed to December 31 of the previous year. To be considered for telehealth use in 2020, requests to add services must be submitted and received by
February 10, 2019.
Two new telehealth services for Prolonged Preventive Services(s) for use in the office or outpatient setting will be reported with Health Care Common Procedure Coding System (HCPCS) G0513 and add-on code G0514 which refer to:
- 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
At this time, these services will only be available in place of service office or the outpatient setting.
Several telehealth provisions of the Bipartisan Budget Act of 2018 will be implemented on January 1, 2019, and include coverage for:
- Monthly clinical assessments related to end stage renal disease (ESRD) 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 when the originating site for these services is the patient’s home.)
- Emergency department (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 unit, or any other site determined appropriate by the Secretary of Health and Human Services.
- CMS is proposing a new modifier that would be used to identify acute stroke telehealth services.
- CMS is seeking guidance on the definition of a mobile stroke unit that could be used to diagnose, evaluate, and treat symptoms of an acute stroke and how these units are used in current medical practice.
There are several additions to the E/M category of codes for 2019, including an overhaul to the documentation guidelines and changes to reimbursement.
In an ongoing effort to recognize the complexities of treating chronic conditions with a patient centered approach, there are two new codes proposed for Interprofessional Internet Consultation allowing payment for certain clinician to clinician services.
- 994X0 Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes; Proposed wRVU of 0.50
- 994X6 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, 5 or more minutes of medical consultative time.
Proposed wRVU of 0.50
Since these codes describe services that are furnished without the patient present, CMS proposes to require the clinician to obtain verbal consent in advance of these services. Such consent would be documented by the treating provider in the medical record.
To analyze the use of postoperative visits during a global surgery period, CMS collected data during 2017 from clinicians in nine states. From July 1, 2017, through December 31, 2017, 990,581 postoperative visits were reported using CPT code 99024. Of the 32,573 practitioners who provided at least one of the 293 procedures during this period, only 45 percent reported one or more visit using CPT code 99024 during this six-month period.
Given the very small number of postoperative visits reported during 10-day global periods, CMS is seeking comment on whether or not it is reasonable to assume that many visits included in the 10-day global packages are not being furnished, or whether there are alternative explanations for what could be a significant level of underreporting. Additional input is also sought on requiring use of modifiers in cases where the surgeon does not expect to perform the postoperative visits regardless of whether or not the transfer of care is formalized.
CMS recognizes that in order to appropriately use E/M services today, there are multiple sources of information to consider, including the 1995 and 1997 documentation guidelines, the Medicare Internet-Only Manuals, and the AMA’s CPT® codebook. CMS’ primary goal in the proposed E/M overhaul is to reduce administrative burden allowing clinicians to focus on patients. E/M visits comprise approximately 40 percent of all allowed charges under the PFS, 20 percent of which occur in the office or outpatient department. Although E/M visits are provided by nearly all specialties, they are reported more frequently by clinicians who do not routinely furnish procedural interventions or diagnostic tests. Additionally, current documentation requirements do not necessarily account for changes in care delivery, such as team-based care, increases in management of chronic conditions, or increased emphasis on access to behavioral health care.
The proposed changes would only apply to office or outpatient visit codes (CPT® codes 99201 through 99215). CMS notes in the rule that due to the relatively broad outline of changes, they anticipate that many details related to program integrity and ongoing refinement would need to be developed over time through sub-regulatory guidance. They further note that the history and exam portions of the E/M documentation guidelines are the most significantly outdated with respect to current clinical practice.
Beginning in 2019, clinicians billing Medicare for office or outpatient E/M visits will have their choice on how to document for code level selection. They may continue in the current framework (using 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. The proposed minimum documentation standard used with the current framework would require clinicians to meet documentation requirements currently associated with a Level 2 visit, regardless of level billed, unless choosing to document based on time.
To be clear, this means clinicians may use Medical Decision Making (MDM), time, or continue to use the current framework to document an E/M visit. At this time, this is a Medicare only proposal, and there is no indication of how other payers will apply this guidance. Therefore, clinicians may choose to continue documenting in the current framework.
The following is the minimum E/M documentation standard (for a Level 2 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 instead 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).
Current time documentation requires that counseling and/or care coordination account for more than 50 percent of the face-to-face patient encounter. CMS seeks to allow clinicians the choice of using time to document office or outpatient E/M visits regardless of whether counseling or care coordination dominate the visit. While time may be a good indicator of complexity of the visit, the clinician need only to document the medical necessity of the visit and show the total amount of time spent by the billing clinician face-to-face with the patient.
Beginning in 2019, CMS seeks to further simplify the documentation of history and exam for established patients and is proposing to 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 and social history. CMS also seeks input on ways to implement a similar provision for medical decision-making and for new patients, considering prior data available to the billing clinician through an interoperable EHR or other data exchange.
The proposal expands that for both new and established patients, clinicians would have the option to no longer be required to re-enter information in the medical record regarding the chief complaint or history that are already entered by ancillary staff or the patient.
CMS indicates 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 proposes to simplify payment for E/M visits Levels 2 through 5.
CMS is proposing to develop a single set of RVUs under the PFS for E/M office-based and outpatient visit Levels 2 through 5 for new patients (CPT codes 99202 through 99205) and a single set of RVUs for visit Levels 2 through 5 for established patients (CPT codes 99212 through 99215). Specialties that tend to bill lower level E/M visits would benefit the most from the proposed change to a single payment rate, while specialties that tend to bill higher level E/M visits would see the largest decreases in payment.
Of the five levels of office-based and outpatient E/M visits, the vast majority of visits are reported as Levels 3 and 4. Data from calendar year (CY) 2016 indicates that Level 3 and Level 4 visits for new patients made up around 32 percent and 44 percent, respectively, of the total allowed charges for CPT codes 99201-99205. Levels 3 and 4 visits for established patients made up around 39 percent and 50 percent, respectively, of the allowed charges for CPT codes 99211-99215.
Eliminating the distinction in payment between visit Levels 2 through 5 is intended to eliminate the need to audit against the visit levels and reduce documentation burden.
CMS has proposed a wRVU of 1.90 for CPT codes 99202-99205, with physician time of 37.79 minutes, and direct PE inputs that sum to $24.98, and similar wRVU of 1.22 for CPT codes 99212-99215, with a physician time of 31.31 minutes and direct PE inputs that sum to $20.70. Tables 19 and 20 from the proposed rule reflect the changes to payment rates in dollars.
Table 19: Preliminary comparison of payment rates for office visits, new patients
|HCPCS code||CY 2018 non-facility payment rate||CY 2018 non-facility payment rate under the proposed methodolody|
Table 20: Preliminary comparison of payment rates for office visits, established patients
|HCPCS code||Current non-facility payment rate||Proposed non-facility payment rate|
While the time for the proposed new payment for E/M visit Levels 2 through 5 is 31 minutes for an established patient and 38 minutes for a new patient, CMS is soliciting comment on appropriate time. One alternative is to apply the AMA’s CPT codebook provision that, for timed services, a unit of time is attained when the mid-point is passed, and would require documentation that at least 16 minutes for an established patient (more than half of 31 minutes) and at least 20 minutes for a new patient (more than half of 38 minutes) were spent face-to-face by the billing clinician with the patient, to support making payment at the proposed single rate for visit Levels 2 through 5 when the practitioner chooses to document the visit using time.
If commenting, consider add-on codes, such as prolonged E/M services which require a typical time for the base visit code to be exceeded by a required amount in order to report prolonged services.
CMS also identified three types of E/M visits that differ from the typical E/M visit and are not appropriately reflected in the current office and outpatient E/M code set and valuation. These three types of E/M visits can be distinguished by the mode of care provided and, as a result, have different resource costs. The three types are:
- Separately identifiable E/M visits furnished in conjunction with a 0-day global procedure
- Primary care E/M visits for continuous patient care
- Certain types of specialist E/M visits, including those with inherent visit complexity
Through this rule, CMS is proposing to create two new G-codes, one specific to primary care and the other to specific specialties. These will be reported in addition to an E/M service to describe the additional resource costs for specialties for whom E/M visit codes make up a large percentage of their total allowed charges, and who historically bill primarily Level 4 and Level 5 visits.
- GCG0X Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology, or interventional pain management-centered care
(Add-on code, list separately in addition to an evaluation and management visit)
Proposed wRVU of 0.25, PE RVU of 0.07, MP RVU of 0.01 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 an evaluation and management visit)
Proposed wRVU of 0.07, PE RVU of 0.07, MP RVU of 0.01 and 1.75 minutes.
These codes could be added to new or existing patient visits, and could include aspects of care management, counseling, or treatment of acute or chronic conditions not accounted for by other codes. CMS expects GPC1X to be used primarily by family practice or pediatrics, and they agree there are situations in which certain specialists function as primary care practitioners — for example, an OB/GYN or a cardiologist. They anticipate that the code will be billed with every primary care-focused E/M visit for an established patient.
Eliminating extra documentation requirements for home visits
CMS is proposing 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
Current practice indicates there is often a work around 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 is seeking comment on whether eliminating this provision could have unintended consequences for clinicians and patients.
Multiple procedure reduction of 50 percent
As part of the proposal to make payment for E/M Levels 2 through 5 at a single PFS rate, CMS is proposing 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) furnishes on the same day to the same patient identified on the claim by modifier -25.
Prolonged E/M option proposed
Currently, clinicians have an option to use 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. Therefore, CMS is proposing to add an additional prolonged E/M code with a reduced time of 30 minutes, meaning a clinician would only need to meet the threshold of 16 minutes in order to bill for it.
- 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 Proposed wRVU of 1.17
Podiatric evaluation and management services
The majority of podiatric visits are reported using low level E/M codes. With the proposed changes to the E/M structure, there is a concern that the consolidated structure does not accurately reflect resource use for podiatric visits. Therefore, two new HCPCS G-codes are proposed for 2019.
- GPD0X Podiatry services, medical examination, and evaluation with initiation of diagnostic and treatment program, new patient
Proposed wRVU of 1.35 with Direct PE inputs of $22.53
- GPD1X Podiatry services, medical examination, and evaluation with initiation of diagnostic and treatment program, established patient
Proposed wRVU of 0.85 with Direct PE inputs of $17.07
While the broad range of E/M changes are proposed to be effective January 1, 2019, CMS is seeking comment on whether to consider a multi-year approach to allow adequate time to educate clinicians and their staff in order to adjust clinical workflows, EHR templates, institutional processes and policies, and other elements that would be impacted by these policy changes. Again, the proposed documentation changes for office/outpatient E/M visits are considered optional, and clinicians could choose to continue to document using the current framework and rules, which may reduce the need for a delayed implementation. More time would also allow for payers to react and potentially adjust their policies.
In 2008, CMS began payment for alcohol and substance abuse structured assessments using G0397 and G0398. However, the utilization for these services has been relatively low, which CMS believes is due in part to the service-specific documentation requirement. With the ongoing opioid epidemic and the current needs of the Medicare population, CMS is proposing to reduce the documentation for these services in 2019 and will add a third option with a lower time threshold when clinicians are unable to meet the original code thresholds.
- GSBR1 -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
According to the Healthcare Cost and Utilization Project, Medicare pays for one-third of opioid-related hospital stays, and Medicare has seen the largest annual increase in the number of these stays over the past two decades. CMS is therefore exploring a separate payment for a bundled episode of care which they believe could reduce such hospital admissions by supporting access to management and counseling services. Comments are sought on how to define and value such a bundle and the attached conditions of payment. As part of this bundle, CMS is also exploring whether the counseling portion and other Medication Assisted Therapy components could also be provided by qualified practitioners “incident to” the services of the billing clinician.
As a result of the Request for Information on CMS Flexibilities and Efficiencies (RFI) that was issued in the CY 2018 PFS proposed rule, CMS is proposing to revise regulations to specify that all diagnostic imaging tests may be furnished under the direct supervision of a physician when performed by an radiologist assistants (RA) in accordance with state law and state scope of practice rules. The 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.
Beginning in 2019, Chronic Care Management (CCM) services furnished by a clinician (as opposed to a clinical staff) will be reported with new code 994X7. 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. RHCs and FQHCs will be paid for G0511 based on the average of the national non-facility PFS payment rates for CPT codes 99490, 99487, 99484, and 994X7.
- 994X7: 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.
Proposed wRVU 1.45
CMS proposes 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 GVCI1 for communication technology-based services, and GRAS1 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 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.
CMS is specifically seeking RHC and FQHC feedback regarding the appropriateness of payment for these services in the absence of an RHC or FQHC visit. It is also interested in the documentation burden for billing these codes and any potential unforeseen impact on the per diem nature of RHC and FQHC billing and payment.
The Bipartisan Budget Act of 2018 (BBA of 2018) requires payment for outpatient therapy services furnished on or after January 1, 2022, in whole or in part by a therapy assistant. In order to prepare for this change, claims for physical therapy or occupational therapy services furnished on or after January 2, 2020, furnished in whole or in part by therapy assistants will require the inclusion of new modifiers to indicate the service was provided by a therapy assistant. Additional modifications will be made to existing modifiers to allow for this change. When therapy is provided by therapy assistants, payment will be made at 85 percent of the Part B payment amount for the service. The reduced payment rate for outpatient therapy services is not applicable to outpatient therapy services furnished by critical access hospitals.
Consistent with the Medicare Payment Advisory Commission’s (MEDPAC) analysis and recommendations, CMS is proposing a 3 percent add-on in place of the 6 percent add-on that is currently being used. Although other approaches for modifying the add-on amount, such as a flat fee, or percentages that vary with the cost of a drug, are possible, proposing a fixed percentage provides consistency with other provisions in the BBA of 2018.
In the CY 2018 PFS final rule, CMS established a start date of January 1, 2020 for the Medicare AUC program for advanced diagnostic imaging services. This requires the ordering clinician to consult specified applicable AUC using a qualified clinical decision support mechanism (CDSM) when ordering applicable imaging services, and the AUC consultation information must be reported on the Medicare claim. During the voluntary testing period from July 2018 through the end of 2019, ordering professionals, who are ready to participate in the AUC program, may consult specified applicable AUC through qualified CDSMs and communicate the results to furnishing professionals. Additionally, early adopters can begin reporting limited consultation information on Medicare claims between July 2018 through December 2019.
AUC consultation and reporting requirements apply in the following locations; a physician’s office, a hospital outpatient department (including an emergency department), an ambulatory surgical center, and any other appropriate provider-led outpatient setting. CMS is proposing through this rule to add independent diagnostic testing facilities (IDTF) as another applicable location to ensure the AUC program is in place across all outpatient settings in which outpatient advanced diagnostic imaging services are furnished. Additionally, to relieve clinical burden CMS further proposes the AUC consultation may be performed by auxiliary personnel under the direction of the ordering professional and incident to the ordering professional’s services.
It is important to note that the ordering professional is ultimately responsible for the consultation as their national provider identifier (NPI) is reported on the claim; 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 (PFS, Outpatient Prospective Payment System, or Ambulatory Surgical Center Payment System).
To implement changes by January 1, 2020, CMS is proposing to use established coding methods to include G-codes and modifiers to report the required AUC information on Medicare claims. They will continue to explore ways to implement a unique consultation identifier (UCI) in future rules. A new HCPCS modifier is also proposed for reporting hardship exceptions. The modifier would indicate that the ordering clinician is self-attesting to experiencing a significant hardship. 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 because it applies to every clinician who orders or furnishes advanced diagnostic imaging services (to include; 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. CMS seeks an implementation approach that is diligent, maximizes the opportunity for public comment and stakeholder engagement, and allows for adequate advance notice to all stakeholders.
Make Your Opinion Known
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-P, Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, MD 21244-1850
Please allow sufficient time to mail comments prior to the closing of the comment period. Comments must be received by September 10 at 5 p.m. ET.