Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

2019 Proposed Medicare Fee Schedule: What You Need to Know

2019 Proposed Medicare Fee Schedule: What You Need to Know

The Centers for Medicare and Medicaid Services (CMS) recently published the proposed Medicare Physician Fee Schedule for 2019. At the heart of the proposal is the annual conversion factor update. After legislatively mandated adjustments, including the .25 percent MACRA increase, for 2019, the proposed conversion factor is $36.0463, a slight increase above the 2018 PFS conversion factor of $35.9996.

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 below.

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 balancing 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 we define “standard charges” 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 we require providers and suppliers 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

CMS also 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 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.

If that sounds like a lot of different options for documenting the same levels of service, you’re right. 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.

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.

Telehealth Additions

As telehealth becomes more widely used and accepted, CMS is proposing to add several new codes and pay for additional services.

First, CMS is proposing to pay separately for two newly defined physicians’ services furnished using communication technology:

  • Brief Communication Technology-based Service, e.g. Virtual Check-in (HCPCS code GVCI1)
  • Remote Evaluation of Recorded Video and/or Images Submitted by the Patient (HCPCS code GRAS1)

According to CMS, practitioners could be separately paid for the Brief Communication Technology-based Service when they check in with beneficiaries via telephone or other telecommunications device to decide whether an office visit or other service is needed. Similarly, the Remote Evaluation of Recorded Video and/or Images Submitted by the Patient would allow practitioners to be separately paid for reviewing patient-transmitted photo or video information conducted via pre-recorded “store and forward” video or image technology to assess whether a visit is needed.

Second, CMS is proposing to add the following codes to the list of approved telehealth services:

  • HCPCS codes G0513 and G0514 (Prolonged preventive service(s))


Finally, CMS has proposed a few important changes to the MIPS program.

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), and providers must earn at least 80 points for an exceptional performance bonus. 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.

Also, the Bipartisan Budget Act of 2018 changed the way MIPS payment adjustments are applied. Under the new guidelines, adjustments will not apply to all items and services under Medicare Part B, but only to covered professional services paid under or based on the Physician Fee Schedule. This change begins with payments issued in 2019 (based on the 2017 performance year), which is the first payment year of the program.

Category Weighting

Reporting categories are weighted for 2019 as follows:

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

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

Promoting Interoperability Performance Category

In addition to receiving a new name, under the proposed rule the Promoting Interoperability (PI) Performance Category would require eligible clinicians to use 2015 Edition CEHRT in 2019. For the first two years of MIPS, providers had the option to use either the 2014 or 2015 Edition CEHRT or a combination of the two.

CMS also is proposing a new scoring methodology for the PI category. They would eliminate base, performance, and bonus scores and adopt a new performance-based scoring at the individual measure-level. Each measure would be scored based on the clinician’s performance for that measure based on the submission of a numerator or denominator, or a “yes or no” submission, where applicable.

Facility-Based Measurement by Individual Clinicians

Finally, 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 beginning 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 is proposing 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.

Learn More; Submit Comments

For more information about the proposed rule or changes affecting the Quality Payment Program, review the following from CMS:

As with all proposed rules, CMS is accepting comments on these and other provisions. You can find the instructions for submitting comments on pages one and two in the proposed rule. Use one of the following ways to officially submit your comments:

  • Electronically through Regulations.gov
  • Regular mail
  • Express or overnight mail
  • Hand or courier

FAX transmissions won’t be accepted.

— All rights reserved. For use or reprint in your blog, website, or publication, please contact us at cipromsmarketing@ciproms.com.


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.

© Copyright 2020