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2019 Proposed Medicare Physician Fee Schedule: What Anesthesiologists Should Know

The Centers for Medicare and Medicaid Services (CMS) recently published the Proposed Medicare Physician Fee Schedule for 2019, including several policy changes relevant to anesthesiologists.

At the heart of the proposal is the annual conversion factor update, both for general Medicare physician services, and also specifically for anesthesia services. After legislatively mandated adjustments, including the .25 percent MACRA increase, for 2019, the proposed conversion factor is $36.05, a slight increase above the 2018 PFS conversion factor. For anesthesia, the proposed 2019 conversation factor is $22.30, also a slight increase from the 2019 conversion factor. See the chart below for a specific comparison of the two conversion factors.

Type 2018 2019
RBRVS $35.9996 $36.0463
Anesthesia $22.1887 $22.2986

In addition to changing the payment rates for 2019, the Proposed Rule also recommended changes to several payment policies. We’ve highlighted a few of the biggest changes most likely to impact anesthesiologists.

Price Transparency

Because “surprise bills” or out-of-network balance billing continue to pose problems for patients and providers alike, CMS is considering ways to improve the accessibility and usability of current charge information, not only from hospitals but also from hospital-based providers who often find themselves in out-of-network balance billing situations with patients.

“We are concerned that challenges continue to exist for patients due to insufficient price transparency. Such challenges include patients being surprised by out-of-network bills for physicians, such as anesthesiologists and radiologists, who provide services at in-network  hospitals and in other settings, and patients being surprised by facility fees, physician fees for emergency department visits, or by fees for providers and suppliers that are part of an episode of care but that were not furnished by the hospital,” drafters of the proposed rule said.

To that end, CMS is seeking public comment from all providers and suppliers on the following:

  • How should “standard charges” be defined in various provider and supplier settings?
  • What types of information would be most beneficial to patients, how can providers and suppliers best enable patients to use charge and cost information in their decision-making, and how can CMS and providers and suppliers help third parties create patient-friendly interfaces with these data?
  • Should providers and suppliers be required to inform patients how much their out-of- pocket costs for a service will be before those patients are furnished that service? How can information on out-of-pocket costs be provided to better support patients’ choice and decision making?
  • Can providers and suppliers be required to provide patients with information on what Medicare pays for a particular service performed by that provider or supplier? If so, what changes would need to be made by providers and suppliers? What burden would be added as a result of such a requirement?

Streamlining Evaluation and Management Services

Anesthesiologists who practice pain management in an office setting should be aware that CMS is proposing a number of coding and payment changes regarding evaluation and management (E/M) visits in the office/outpatient setting. Specifically, CMS is proposing to allow practitioners to document office/outpatient E/M visits and choose appropriate levels of service using any of the following:

  • medical decision-making,
  • time, or
  • the current framework of choosing either 1995 or 1997 E/M documentation guidelines.

Additionally, CMS is proposing that the documentation of history and exam focus on what has changed since the last visit or on pertinent items that have not changed, rather than having practitioners re-document information, provided they review and update the previous information. As well, CMS plans to allow 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.

Wondering how all those options translate into payment? CMS is proposing new, single blended payment rates for new and established patients for office/outpatient E/M level 2 through 5 visits, plus a series of add-on codes to reflect resources involved in furnishing primary care and non-procedural specialty services. That means one payment amount for new patients and one for established patients, regardless of the level of service.

As such, CMS would require only minimum documentation—what would currently support a level 2 CPT visit code—for history, exam and/or medical decision-making in cases where practitioners choose to use the current framework or medical decision-making as the governing factor. In cases where practitioners choose to use time to document E/M visits, the documentation standard would include only the medical necessity of the visit and the total amount of time spent by the billing practitioner face-to-face with the patient. And when E/M visits are furnished in conjunction with other procedures, CMS has proposed a multiple procedure payment adjustment that would apply in those circumstances.

CMS is soliciting public comment on the implementation timeframe of these proposals, as well as how to update E/M visit coding and documentation in other care settings in future years.

MIPS

Finally, CMS has proposed a few changes to the MIPS track of the Quality Payment Program that may impact anesthesiologists.

Low-Volume Threshold and Opt-in

First, CMS proposed a third criterion for determining MIPS eligibility. For 2018, clinicians or groups were excluded from MIPS if they had ≤ $90K in Part B allowed charges for covered professional services or if they provided care to ≤ 200 beneficiaries. In addition to those two criteria, for 2019, clinicians or groups may be excluded if they provide ≤ 200 covered professional services under the Physician Fee Schedule (PFS).

However, CMS also is proposing a new opt-in feature for excluded clinicians and groups. For 2019, clinicians or groups would be able to opt-in to MIPS if they meet or exceed one or two, but not all, of the low volume threshold criterion.

Scoring and Payment Adjustments

Next, for 2019, providers must earn a final score of at least 30 points to avoid a negative payment adjustment (only 15 points were needed in 2018). Providers who receive a final score at or above this performance threshold receive a zero or positive payment adjustment and a score below the performance threshold would result in a negative adjustment. As required by statute, the maximum negative payment adjustment is -7 percent, and positive payment adjustments can be up to 7 percent, but as in the past, they are multiplied by a scaling factor to achieve budget neutrality.

Category Weighting

Reporting categories are weighted for 2019 as follows:

  • Quality: 45 percent
  • Cost: 15 percent
  • Promoting Interoperability: 25 percent
  • Improvement Activities: 15 percent

This represents a slight change from 2018 when Quality represented 50 percent of the final score, and Cost only 10 percent.

Facility-Based Measurement by Individual Clinicians

In the 2018 final rule, CMS established individual eligibility criteria for MIPS eligible clinicians who furnish 75 percent or more of their covered professional services in sites of service identified by inpatient hospital or emergency room POS codes to be evaluated under facility-based measurements used in the Hospital Value-Based Purchasing (VBP) Program rather than MIPS scoring.

With this change set to take effect in 2019, CMS will automatically apply facility-based measurement to MIPS eligible clinicians and groups who meet the eligibility requirements and who would benefit by having a higher combined quality and cost score. There are no submission requirements for individual clinicians who receive facility-based measurement, but groups must submit data in the Improvement Activities or Promoting Interoperability performance categories in order to be measured as a group under facility-based measurement.

In the 2019 proposed rule, CMS plans to modify what defines a “facility-based individual” in four ways.

  • First, they will add on-campus outpatient hospital (as identified by POS code 22) to the settings that determine whether a clinician is facility-based.
  • Second, CMS will require a clinician to have at least a single service billed with the POS code used for the inpatient hospital or emergency room.
  • Third, if they are unable to identify a facility with a VBP score to attribute a clinician’s performance to, that clinician is not eligible for facility-based measurement.
  • Fourth, CMS will align the time period for determining eligibility for facility-based measurement with the dates used to determine MIPS eligibility and special status.

This change could mean that as many as 72.55 percent of anesthesiologists would be eligible for facility-based measurement, whereas under the original guidelines, only 13.45 percent of anesthesiologists would have been eligible.

For more information about the 2019 Proposed Medicare Physician Fee Schedule, review the following from CMS:

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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